RIVER
PARISHES
COMMUNITY
COLLEGE
P.O. Box 2367 • 925 W. Edenborne Pkwy. • Gonzales • Louisiana • 70437
(225) 743-8500 • FAX (225) 644-8210 • http://www.rpcc.edu
Received By:_________________
River Parishes Community College
General Appeal Request Form
Name: _________________________ Date: ____________ LOLA ID#:___________________
Telephone Number: ______________________ E-mail address: ___________________________
Complete Mailing Address: ____________________________________________________________
Basis for Appeal:
Clearly describe the circumstances surrounding your appeal.
Please include all pertinent details in a chronological format and attach all relevant
supporting documentation.
The appeal may be typed or hand written.
Please attach your statement to this form and turn it in to Student Services.
Remember – an executive committee will make a decision based upon the information
you provide.
Once your appeal is reviewed by the Appeals Committee and a decision is made, you will
be notified by email of the decision.
The decision of the Appeals Committee is final.
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Committee Decision: _____ Approved _____ Disapproved
Comments: ___________________________________________________________________
______________________________________
_________________
(Authorized Signature)
(Date)
______________________________________
_________________
(Financial Aid Office)
(Date)
______________________________________
_________________
(Registrar's Office)
(Date)
_____________________________________
_________________
(
Business Office)
(Date)
The River Parishes Community College a member of the Louisiana Community & Technical College System
Accredited by the Southern Association of Colleges and Schools does not discriminate on the basis of race, color, national
origin, sex, disability, or age in its programs and activities and provides equal access to the Boy Scouts and other designated
youth groups. The following persons located at 925 W. Edenborne Pkwy, Gonzales, LA – 225-743-8500 have been designated
to handle inquiries regarding the non-discrimination policies:
Julian Surla– Title IX Coordinator Shalither Cushenberry – Section 504 Coordinator
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