Waycross Campus (912) 287-6584
Jesup (912) 427-5800
a (912) 632-0951
Camden (912) 510-3327
Hazlehurst (912) 379-0041
Baxley (912) 367-1700
Golden Isles (912
Aid Year: 2020-2021
ype or Prin
Full Name (last, first, and middle initial)
CPTC – Student ID Number
Date of Birth
The Office of Financial Aid has received information from the National Student Loan Data System (NSLDS) regarding an
‘unusual enrollment history’ during your post-secondary education. The information below must be submitted to our office
to assist in the determination of your Federal Financial Aid eligibility. Our office will then review the information you have
provided and may request additional documentation if necessary. We recommend that you submit all requested
documentation within 14 calendar days of receipt of this notice.
Please visit the National Student Loan Data System (NSLDS) at www.nslds.ed.gov to assist you in filling out the
following chart. You will need your Federal Student Aid (FSA) ID username and password in order to access this
information. List information for the 2016/2017, 2017/2018, 2018/2019 and 2019/2020 Aid Years.
If you failed to earn academic credit at any school listed above, please explain why:
(attach an additional sheet if necessary)
I certify that all information reported on this worksheet is complete and correct.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
As set forth in the student catalog, Coastal Pines Technical College (CPTC) does not discriminate on the basis of race, color, creed, national or ethnic origin, gender,
, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in those special circumstances permitted or
mandated by law). The following persons have been designated to coordinate the College’s implementation of non-discrimination policies: Katrina Howard, Title IX
Coordinator, Jesup Campus, Office 132, email@example.com , 912.427.5876; Cynthia Linder, Office 1439, Title IX Coordinator, Waycross Campus,
firstname.lastname@example.org , 912.287.4098; and Cathy Montgomery, ADA/Section 504 Coordinator, Golden Isles Campus, Office 1141, email@example.com ,
2021 Unusual Enrollment History Verification Form draft 1Verification Rev.03/12/2020
click to sign
click to edit