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Please fill out this form and submit it: by fax to: (908) 689-5824 or by mail to:
Registrar, Warren County Community College, 475 Route 57 West, Washington, NJ 07882
Student Signature: ___________________________________________ Date: ________________________
Contact Information
Student ID number: ________________________ Major: _______________________________________
Name: ______________________________________
Address: _____________________________________________________________
City: ________________________ State: _________ Zip: _________________
Telephone: (_________) __________ - ________________
E-mail: __________________________________________
You must list a specific course name and code in each category, not an elective category. For courses
which have been approved as transfer credit, please list the WCCC course code assigned to the course.
Please consider: __________________________________________________________________________
course you have taken or are currently taking (example: CSC-103 Introduction to Computing)
Is this a WCCC course? Yes No (If no, at what college was it taken?______________________*)
*substitutions for courses taken at other institutions require that an official transcript have been submitted to
WCCC and evaluated for transfer credit. Please list the course for which transfer credit was assigned.
to fulfill the requirement of: ________________________________________________________________
course required for your degree (example: CSC-112 Computer Software Applications
Please provide a detailed rationale for your request: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
If necessary, continue on back of this page
Type your full name, or print this document and apply your
signature to the above line.
