Name ________________________________		Social Security Number ____________________
Address ______________________________                 ______________________________		Telephone Number _______________________
Type of Grievance / Appeal:		Return This Form To:
Academic Dishonesty Educational Guarantee Graduation Requirements	____  ____  ____	Vice President for Instruction
Tuition and Fees or other  Balances Due Issues	____	Vice President for Finance and Administration
Accommodations for  Persons with Disabilities  Harassment of Any Nature  Title IX Issues	____  ____  ____	Director of Human Resources / Affirmative Action Officer / Title IX Coordinator
Academic Probation or Suspension Advisement Issues  Conduct Family Education Rights and Privacy Act Financial Aid Issues Residency Transfer Credit Guarantee	____ ____ ____ ____ ____ ____ ____	Vice President for Student Services
Details of Your Grievance / Complaint and Suggested Resolution: Please use the back of this form to describe your grievance / complaint in detail including all the steps you have taken to resolve the issue through the informal process. (If you have not attempted to resolve the issue through the informal process this request for a formal resolution will be denied.) Additionally, please suggest what you think is a fair resolution to the issue.
Signature ________________________________		Date __________________________________