INFORMATION REQUEST NAME: REQUEST DATE: INFORMATION REQUESTED: REASON FOR REQUEST: WHEN IS INFORMATION NEEDED: _________________________________________________________________________________ PRINT NAME SIGNATURE _________________________________________________________________________________ DATE **PLEASE RETURN BY MAIL OR FAX** MAIL FAX ORANGE COUNTY COMMUNITY COLLEGE 115 SOUTH STREET 845-341-4670 "MIDDLETOWN, NEW YORK 10940" ATTENTION: PAYROLL DEPARTMENT