Student Form
Date:
Student Information
Indicates required fields *
First Name:
*
Last Name:
*
Tartan ID:
*
E-mail:
Best phone number to call:
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Academic Program Major:
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I prefer a
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Phone Call
Appointment
E-mail
Does this pertain to a certain course(s) of yours?
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Yes
No
[
If yes, please indicate Department/Course/Section i.e.
(ex BIS.130.02)
]
Course
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Current Term
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--Please Choose One--
Fall 2009
Winter 2010
Spring 2010
Summer 2010
Fall 2010
Winter 2011
Spring 2011
Summer 2011
Campus:
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--Please Choose One--
Dayton
Huber Heights
Preble County
Englewood
Courseview
Briefly describe your issues/complaints or reason for contacting the Ombudsman
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Human Validation
Please type the letters as you see them in the image above. The letters are case sensitive