TUITION CREDIT REQUEST FORM Tuition Credit Review Committee Shepard Student Center Room 318 Orange County Community College 115 South Street, Middletown, NY 10940 _________________________ ___________________ ___________________ Name A# Today�s date _________________________________________ _________________________________________ _________________________________________ (____)___________ Address Phone Number LIST ALL COURSES YOU ARE REQUESTING A CREDIT FOR: Course# Course Name # Credits Non-credit Semester/Year __________ _________________ ________ _______ ___________ __________ _________________ ________ _______ ___________ __________ _________________ ________ _______ ___________ __________ _________________ ________ _______ ___________ REASON FOR REQUEST (check one) * Medical situation Academic course errors Military activation RATIONALE (Please feel free to attach additional sheets if necessary. Please be sure to submit copies of supporting documentation.) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student Signature____________________________________ Date______________ Mail the completed form and all supporting documentation to the above address or place it in the Bursar�s Office Drop Box. 04/27/2009