H-SC Room Damage Appeal Form

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Name:    _________________________________________________________________________

                        First                              Mi.                                   Last

Student ID#:  _____________              Building:______________            Room#:__________

Cell#:  _________________________      E-mail address: ________________________________

Damage being appealed: ___________________________________________________________

Charge amount: $______________            Folio#:_______________  (WO#: 123456/YED)

Reason for Appeal:  ________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Please be aware that submission of the appeal form does not guarantee that a damage charge will be removed from your student account.

______________________________________                           ____________________________

                    Signature                                                            Date Submitted

Please complete all information requested above and fax form to:  Wes Lawson, Associate Dean of Students, (434-223-6040), e-mail a copy to wlawson@hsc.edu or mail it to his attention at PO Box 5, Hampden-Sydney, VA  23943.