Clery Act Student Travel Form

Clery Act Student Travel Form
This form is to be completed for any University-related overnight travel That includes students such as athletics, academics, club/organization, etc.
Group Name*
Travel Contact - Name*
Travel Contact - Title*
Travel Contact - Department*
Travel Contact - Phone*
Travel Contact - Email*
example@example.com
Travel Date - Departure from MSU*

MonthDayYear
Date
Travel Date - Return to MSU*

MonthDayYear
Date
Lodging Facility Information:

Note: If group is staying at more than one lodging facility, please complete a separate form for EACH facility.
Lodging Facility - Name*
Lodging Facility - Street Address*
Lodging Facility - City, State, Zip*
Lodging Facility - Specific floor(s), room number(s), or unit number(s) occupies*
This trip is:*

a one-time triprepeated each semesterrepeated annuallyOther
If trip is repeated, our group:

always stays at the exact same lodging facilityuses various lodging with each trip
Please select one (1):*

To the best of my knowledge, no crime was committed in this place of lodging during the dates of our stay.During the time period of our stay the following crime was reported to have occurred at this place of lodging. Please refer to page two.
Please include as much detail as possible regarding the crime, include date and time of crime, type of crime,weather of not the victim is student or non-student of Minot State University.
Person submitting this form:
Name*
Signature*

Clear
Date*

MonthDayYear
Date
Please include as much detail as possible regarding the crime, include date and time of crime, type of crime, weather of not the victim is student or non-student of Minot state University.
Should be Empty:

Clery Act Student Travel Form

Lodging Facility Information:

Person submitting this form: