Fill - Free fillable Student Academic Inquiry (Elizabeth City State University) PDF form

Elizabeth City State University

Office of the Vice Chancellor for Academic Affairs

Student Academic Inquiry Form

: Before delivering this Form to the Office of the Provost and Vice Chancellor for Academic

Affairs, you must seek assistance, obtain signatures with current date from each of the following

individuals in the box below. Obtaining signatures indicate you have followed the “chain of command” to

have your request/inquiry resolved. If there are questions regarding this form, you may contact the Office

above at: 252-335-3291.

Instructor: ___________________________/Date: __________ Advisor: ___________________________/Date: __________

Chair: ___________________________/Date: __________ Dean: ___________________________/Date: __________

Date______________________ Banner I.D. #_______________

Last Name___________________________ First Name___________________________ MI________

Current Mailing Address_______________________________________________________________

City__________________________ State__________________________ Zip Code_______________

Home Phone___________________Cell_____________________Email________________________

Classification: Freshman Sophomore Junior Senior Gr. Senior Other______________

Major______________________ Cumulative GPA ________ Advisor __________________________

Nature of Inquiry____________________________________________________________________

___________________________________________________________________________________

(More lines, if needed, on reverse side/next page of this form. Attach additional forms/letters if necessary.)

If you are completing this Form for the ECSU student with a request or inquiry, please provide us with the following:

(Please Print)

Last Name__________________________________ First Name________________________________ MI____________

Relationship to Student____________________

FOR OFFICE USE ONLY. DO NOT MARK BELOW THIS LINE

Mark Accordingly

Action Taken

___________________________________________________________________________________

________Issue Forwarded to Vice Chancellor for Academic Affairs or Others

Name: _________________________________ Date: ____________________________

Nature of Inquiry

Continued

_______________________________________________________________________________

______________________________________________________________________________________

Revised: 03/05/14 RBW

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