Student Complaint Form - West Virginia Higher Education Policy Comission Page 2
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2The information you provide will be used in efforts to resolve your complaint and will be shared
with the school. By submitting this complaint and the accompanying FERPA Consent and
Release Form, you are giving the West Virginia Council for Community and Technical College
Education or West Virginia Higher Education Policy Commission permission to contact school
officials to discuss a possible resolution to your complaint.
Signature:____________________________________
Date:______________
STATE OF WEST VIRGINIA
COUNTY OF _______________
I, ____________________________________ a notary public in and for said state do hereby
certify that _____________________________, whose name is signed to the writing above,
has this day acknowledged the same before me.
Given under my hand this _____ day of _______________, ____
My Commission expires _____________________________
__________________________________________________
{stamp}
Notary Public
Council/Commission Use Only:
Date Received:
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CCTCE Jurisdiction?
Yes
No
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HEPC Jurisdiction?
Yes
No
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Classification of Complaint:
Ac
Adm
Fin
FA
Oth
Mail or Fax all complaints with associated documents to:
Executive Vice Chancellor for Administration
West Virginia Council for Community and Technical College Education
West Virginia Higher Education Policy Commission
1018 Kanawha Boulevard, East
Suite 700
Charleston, WV 25301
Fax: 304.558.5719
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