Student Customer Service Form

STUDENT CUSTOMER SERVICE FORM

Student Information

Date of Birth:     Grade / Program:

Contact Information

Preferred contact method: Phone Email Mail

Request Details

Please indicate the service requested (select all that apply):

Transcript request
Enrollment verification
Grade or record change review
Disability or academic accommodation request
Billing/account inquiry or adjustment
Legal name change on record
Other (describe below)

Desired resolution or outcome:

If this request is time-sensitive, indicate reason and target date:

Authorization, Privacy and Fees

By signing below, I certify that the information provided on this form is true and correct to the best of my knowledge. I authorize the institution to access and process my educational record as necessary to complete this request. I understand that release or correction of records will be conducted in accordance with applicable privacy laws and institutional policy.

I acknowledge that some requests may incur administrative fees or require additional supporting documentation. I accept responsibility for any fees assessed for processing this request and understand that processing may take up to ten business days from receipt of a complete request unless otherwise noted by the office.

Consent to release records to third parties (if applicable):
I authorize release to the individual or organization named below.

Relationship of signatory to student:

Supporting Documentation

Attach copies of any supporting documentation with this request (transcripts, identification, legal documents, medical documentation for accommodations, etc.). Failure to provide necessary documentation may delay processing.

Administrative Use Only

Received by:     Date received:

Action taken:

Fee assessed (if any):     Date completed:

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