Inadvertent Enrollment Report Form
Report an unintended enrollment and request follow-up or resolution.
Reporter name
*
First Name
Last Name
Reporter email
*
example@example.com
Date the report is submitted
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of the unintended enrollment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of the program, service, or offering
*
Non-sensitive account or enrollment reference
Describe how the unintended enrollment occurred
*
How did you discover the enrollment?
*
Requested resolution or next step
*
Optional supporting file
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