Cooperative Agreement Request

Cooperative Agreement Request
To be considered for a cooperative agreement or chargeback, you must:
1. Live within the boundaries of District 520
2. Enroll in a degree or certificate program which is different in name and purpose from any offered at KCC.
3. Submit a completed cooperative agreement/chargeback request.
  Learn more about cooperative agreements and chargebacks.
To verify residency, KCC must have a copy of your driver's license, state ID or voter's registration card. If you are unable to upload a file using the form below, visit KCC's riverfront campus, complete a paper form and bring one of the IDs listed above.
Upload a copy of your driver's license, state ID or voter's registration card to verify residency.

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Full Name *

First Name Middle Name Last Name
Student ID
Enter your seven-digit KCC student ID
Birthdate *

Month Day Year
Phone *
Email *
example@example.com

I certify: *

I understand that this program is not being offered at Kankakee Community College. Should I fail to enroll in the above mentioned program, I shall assume all responsibility for tuition and fee expense incurred in my enrollment at the approved institution. I hereby understand that the approved school will permit me to study in the program that I have requested at their in-district tuition rate provided that I stay within the guidelines of the program. Deviation from the program will result in my paying out-of-district tuition rates. Marking "I Agree" indicates that I understand this agreement is for the program specified above. I Also Understand that distance is not considered a basis for approving Cooperative/Chargeback Agreements. If a program is offered anywhere within the cooperative network, it is judged to be available. The time of day, day of the week, the particular semester or term of offering, or the program or its component parts are not considered as factors affecting approval. Cooperative/Chargeback Agreements are not available for transfer programs. I further certify that the information contained in the notification is true and correct.
Signature

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FOR OFFICE USE ONLY

 Residency verified  Program verified

 Approved for cooperative agreement  Disapproved for cooperative agreement

Date: __________________ Authorized signature: __________________
Should be Empty:

Residency