Dean's Certifications & Disciplinary Records Request

Student's Background Information

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

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This should be the one you use the most frequently

Today's Date(Required):

This field is required.

Confirming Student's Information

You must provide your name and Bergen student ID number. This information may be the same as the background section above. This information is important should we need to contact you.
If you do not know/recall your Bergen student ID number, you may leave that field blank.

Name

Bergen ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Questions

Which of the following is this request for?(Required) This field is required.

Dates of Attendance at Bergen Community College (Semester-YYYY) to (Semester-YYYY)(Required) This field is required.

Did you graduate from Bergen Community College?(Required)

Yes No Current student

This field is required.

Is your current name, the same name you had while attending Bergen Community College? This field is required.

If no, what other name(s) did you use while attending Bergen Community College? This field is required.

FOR EMPLOYMENT WITH LAW ENFORCEMENT AGENCIES: If you are in the application process for a law enforcement position and need a copy of your disciplinary records, please list the agency(s) that you are applying to. This field is required.

FOR TRANSFER STUDENTS: If a College Official has to submit your College/ Transfer Report to the institution you are applying to, please provide the institution's NAME and EMAIL address. Please list ALL institutions. Also, some schools allow you to submit your College/ Transfer Report on your own. If this is the case, please put "N/A" for this question.(Required) This field is required.

Supporting Documentation

Additional information concerning Bergen Community College's disciplinary release policy can be found online here. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Student's Background Information

Confirming Student's Information

Questions

Supporting Documentation

Submission