REQUEST FOR TUITION REFUND OR CREDIT
c/o BUSINESS OFFICE
Orange County Community College | 115 South St., Middletown, NY 10940

Name _______________________________ SS#__________________

Semester Requested: __________________

Address ___________________________________________________

Phone Number: _____________________________________________

All requests must be in writing, no phone calls or in person requests will be accepted. You must provide documentation to substantiate your request. For details please refer to the SUNY Orange College Catalog, Refund
Policies.

No requests will be accepted unless the student has "officially" dropped the class in question. Drop slips are available in the Records & Registration Office.

LIST ALL COURSES YOU ARE REQUESTING A REFUND OR CREDIT FOR:

Course# .......... Course Name ........................# Credits..... Non-credit

____________ ________________________ ________ ___________

____________ ________________________ ________ ___________

____________ ________________________ ________ ___________

____________ ________________________ ________ ___________

REASON FOR REQUEST___________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Student Signature________________________Date___________________