PROGRAM CHANGE REQUEST
Student Status:
Applicant Current Former
Student ID #:
(No dashes or dots)
Last Name: First Name: Middle Initial:
New Program Requested:
Program Type:
Degree Diploma Certificate
Current Program of Study:
Program Type:
Degree Diploma Certificate Clarkston Covington
Effective Term:
Term: Year:
(For CTD Only)
Day Evening
Student Authorization:
If I receive HOPE grant funds during my matriculation at Georgia Piedmont Technical College and I decide to change back to a degree program at anytime, I
understand that I will be responsible for any fees incurred from the date of the change forward if I am not eligible for other forms of financial aid.
I understand that I must consult with the Financial Aid Office to see if my fees will be covered if I change my program of study.
I acknowledge that entering my name on this form is the equivalent of my signature. By submitting it I
authorize the Georgia Piedmont Technical College Admissions Office to process my request.
Student Name: Date:
Georgia Piedmont Technical College does not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age, political affiliation or
belief, disabled veteran, veteran of the Vietnam Era, or citizenship status (except in those special circumstances permitted or mandated by law).
CASHIER'S OFFICE USE ONLY:
Date Paid Initials
ADMISSIONS OFFICE USE ONLY:
Change Processed ____/____/_____ Initials
PLEASE COMPLETE IF YOU WOULD LIKE TO PAY BY CREDIT CARD (fax request to 404-298-3617):
STUDENT AUTHORIZATION: I,
AUTHORIZE GEORGIA PIEDMONT TECHNICAL COLLEGE
TO CHARGE MY CREDIT CARD THE AMOUNT OF $
TYPE OF CREDIT CARD:
EXPIRATION DATE:
NAME THAT APPEARS ON CREDIT CARD:
SIGNATURE:
PRINTED NAME:
VISA
MASTERCARD
DISCOVER
CREDIT CARD NUMBER:
(MM/YY)
Campus:
