Transfer Services Form

With the exception of the comments field, all fields are required!

Faculty/Staff Name:

Phone:

Email:

@qcc.mass.edu

Office:

Course Title:

Course Number & Section:

Room Number:

Building:

Number of Students:

Is there Media Access in the Class or Meeting room?

CPU and LCD projector? Yes No
Internet Access? Yes No

IF YOU SELECTED NO, please click: Media-Services to request the CPU\LCD and Internet access.

Visit Request Date Information (select as indicated):

First-Choice-Date:

Day of Week:

Time of Day:

Please check only if there are no possible "Second Choice Dates" and leave the second choice fields as they are.

Second-Choice-Date:

Day of Week:

Time of Day:

Presentation choice (Indicate any specifics) - please choose one.

50 minutes – includes overview of Transfer Services, Transfer Programs and related issues. Orientation and the practical use of the Transfer office website with Q & A.

15 minutes – includes a brief overview of Transfer office, services and programs. Includes a brochure with information for accessing transfer resources.

Please check-off to affirm that you understand Faculty/Staff must be in attendance during the presentation.

Additional Comments:

Please note that all requests are subject to availability. Transfer Services will contact you to confirm the visit and to discuss any issues. You will receive a form submission confirmation email shortly after submitting this form.

Thank You!