Student Inquiry and/or Incident Report
Name (Please print):__________________________________
Banner ID#:________________________________________
Date:______________________________________________
Phone:_____________________________________________
E-Mail:_____________________________________________
Briefly describe the main points of your complaint. Include the steps you have taken to resolve your
complaint consisting of the date of incident, persons whom you have been in contact with, and the
department(s). Explain what you might consider to be a satisfactory resolution to your complaint.
You may attach any supporting documentation you may have to accompany your complaint. Please
keep in mind that your complaint will be directed to the originating/relevant department for
resolution. Once completed please submit form to the Office of the Registrar.
Please describe the main points of your complaint below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Registrar:______________________
Date:___________________
Notes:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Office of the Registrar
ATTN: Dr. Althea A. Riddick
1704 Weeksville Rd.
Campus Box 953
Elizabeth City, NC 27909