Dean's Certification & Disciplinary Records Request (Students/Alumni/Former Students)

Entity to Whom to Release Information

Please complete the following fields to whom you wish for the University to release your disciplinary records. This contact information is vital in case we need to you or the entity. If you have a specific form that needs to be completed, please attach it at the end of this request.

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Contact Person's Name:

Title/Role:

Phone number:

Email address:

Email address must be of a valid format.

Name of Company/Agency:

Who is this report for?(Required):

This field is required.

Date of Request(Required):

This field is required.

Student/Alumni Information

Your Full Name

Select Gender

Select UIC Student Status

Your UIN

Your DOB (YYYY-MM-DD)

Your Phone number

Your Email address

Your Full Address

Information for Records Release

Dates of Attendance at UIC (YYYY-MM-DD) to (YYYY-MM-DD).(Required) This field is required.

Please list how you like the records disclosed to the entities identified above (e.g., form, email, mail). If you want these records sent to you, please indicate how you would like to receive them.(Required) This field is required.

Is your current name, the same name you had while attending UIC?(Required)

Yes No

You must make at least one selection.

If NO, what was your name while attending UIC? This field is required.

Your UIC College affiliation?(Required) This field is required.

Any other comments or specific requests? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Entity to Whom to Release Information

Student/Alumni Information

Information for Records Release

Supporting Documentation

Submission