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Change of Legal Status Disclosure

This form should be submitted by UMMC employees and non-employees to disclose any changes to their legal status that may have occurred since the time of receiving fingerprint clearance. All have an affirmative obligation to immediately disclose any changes to their legal status including charges resulting from arrests, criminal convictions of both misdemeanor and felony crimes, and addition to a sex offender registry. UMMC students should not utilize this form, but should instead disclose any legal changes to the Dean of their Program of Studies or their designee.

This form will be securely routed to the Human Resources Employee Relations for review. It is important that you include information about the disposition of the event (guilty, nolo contendere, non-adjudicated, charges are pending, etc). You may use the attachment option to attach any relevant court documents, police records, or other official documents for consideration.

Name* 
Worker ID Number
Role/Position at UMMC* 
Telephone Number*() - ext.   
Email Address* 
Description of Change* 
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Attachment
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By submitting this form, I attest that the information that I have provided is true and accurate. I understand that my clearance to work at UMMC may be revoked at any time in response to this disclosure. I release UMMC and its agents, officers, employees, attorneys, and representatives of all liability associated with work authorization decisions or actions based in whole or in part on compliance with or attempts to comply in good faith with the requirements of Miss. Code Ann. § 37-115-41, 45-33-59, or 43-11-13.