Licensure and Certification Disclosure Acknowledgement

Please complete this form before the first day of class each semester. If this form is not submitted by the first day of class, you will be placed on administrative hold until the form is completed.

Name(Required)

First Last

Student ID Number

Email(Required)

Program(Required)

Do you plan to pursue licensure or certification?(Required)

Yes

No

Current State of Residence(Required)

Planned State of Residence upon Graduation(Required)

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Online Payments Portal

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Online Payments
Are you a current student?*
Faulkner Student ID Number*
Enter ID Number
######*
Confirm ID Number
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Personal Phone*
Work Phone
Email*
Payment Information
Payment Description*
Social Security Number*
Date of Citation*
MM slash DD slash YYYY
License Plate Number*
Location of Violation*
Date of Citation*
MM slash DD slash YYYY
License Plate Number*
Location of Violation*
Report Number*
Please select your status*
- New student/transfer student
- Returning student
Quantity of Transcripts Requested @ $30/ea.*
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Would you like to put down the payment for your tool kit today and have your equipment by the first day of class?*
This will save you 3% percent fee at a later date. This tool kit is mandatory.
Tool Kit Deposit*
Price:
This will be added to the $500 DPT Deposit.
NOTE: Not paying for the mandatory tool kit with your DPT Deposit will result in a 3% convenience fee.

To pay for your Tool Kit at a later date, return to this Payment Portal, and pay $110 dollars via the 'Other' payment option.
Name of Child in Pre-K*
First Name Last Name
Graduation Month
Graduation Month*
Graduation Year*
Please Note: This form does not apply to J.D. or LL.M. graduates. For more information, please refer to J.D. and LL.M. graduation information or email Dean DeBoer (jdeboer@faulkner.edu) any questions.
Note: This fee is non-refundable except in the event that the program fails to receive accreditation.
Other Payment Description*
Law School Organization Name*
Please Note: This is a payment portal only. To complete a transcript request application, visit the Transcript Request section of the Registrar page and follow the instructions.
Please select your deposit amount*
- $200 refundable deposit (until May 1 of entry year)
- $1000
- Other
Amount*

Minimum of $5.00 required.
Other Amount*
3% Convenience Fee
Price: $0.00
3% Convenience Fee
Price: $0.00
Amount*

Please note that if this graduation application payment is late, you will need to pay an additional $50.
How should this be applied?
- Student's trip
- Mission Trip Fund
Please list the student:
3% Convenience Fee
Price: $0.00
Total
$0.00
The graduation application is closed. Please refer to https://faulkner.edu/student-life/registrar/ for more information.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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First Name	Last Name