Revised 9/30/16
State Authorization Reciprocity Agreement
North Carolina (SARA NC)
Student Complaint Form
First Name: Middle Initial: Last Name:
Address: City: State: Zip:
Primary daytime phone number: Alternate daytime phone number:
Email address:
Preferred method of contact: Phone Email
I am submitting a complaint against located in North Carolina.
Institution Location City:
Did you use a different name at the time of enrollment?
If yes, please provide.
Name of program of study:
Program start date: Program end date:
Current enrollment status:
Currently attending above institution: Yes No Last date of attendance:
Graduated: Withdrew/terminated: Other:
Complaint information
Student must follow the institutional complaint process provided by the college or university before
submitting a complaint to the State Portal Agency (NCSEAA). Did you submit a complaint to the
institution according to their complaint policy? YES NO
Please submit documentation that you have exhausted your appeals with the institution. You should
include documentation that you submitted to the institution regarding your complaint and any letters
from the institution documenting its final decision regarding your complaint. Documentation should
be submitted by U.S. Mail to: SARA North Carolina Director, NCSEAA, PO Box 14103, Research Triangle
Park, NC 27709 or email to complaint@saranc.org
.
Please keep a copy of your submission to NCSEAA for your records.
Revised 9/30/16
Please describe your complaint in detail, including the nature of the incident, dates and names of
individuals involved and institutional employees with whom you have discussed your complaint. You
may submit on a separate document.
How would you like to see your complaint resolved? For example, do you want a refund of tuition or
to repeat a class?
I certify that the information provided on this form is true and correct to the best of my knowledge
and belief. By submitting this form, I understand that I am granting permission to the NCSEAA as the
State Portal Entity and members of the SARA North Carolina Advisory Council to contact institution
officials to discuss my complaint and a possible resolution.
Signature:
Date:
___ _
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