California State University, Monterey Bay
STUDENT DISABILITY RESOURCES (SDR) Health and Wellness Services (Bldg. 80) Mail: 100 Campus Center Seaside, California 93955-8001 831.582.3672 (phone) 831.582.4024 (fax) email: [email protected] URL: https://csumb.edu/sdr
Semester Fees Request for Department of Rehabilitation Consumers 1. Semester/Year: Fall _______
Spring______ Winter _____
Summer _____
Semester start date: ________ End date ________ See Academic Calendar 2. Dept. of Rehabilitation Counselor Name: _____________________________________________
Phone:_________________
3. Student’s Name:_________________________________ Student ID:______________ 4. Registration Fees: No fee required; student receives the following financial aid: PELL, SEOG, EOPS, CARE, or CAL Grants Fee required for_____ X $______ = ______ units Registration Total Student Fee $______ $__________ Parking ($54/sem) $______ (Check payable to: CSUMB Cashier. Indicate that it is for parking and registration.) 5. Books
$______
6. Supplies
$______
Books/Supply Total $__________
(Check payable to: CSUMB Bookstore) 7. Printing at CSUMB (extra if needed): https://csumb.edu/it/printers Printing Total (Check payable to: CSUMB Cashier) $__________ Grand Total $__________ Optional: SDR Staff__________________________________ Date _______________ Send DOR Authorization forms for tuition and fees to:
ATTN: Robin Chase CSUMB Cashier’s Office 100 Campus Center Seaside, CA 93955-8001 Fax: 831/582-3399
Department of Rehabilitation Authorization Worksheet for Supplies For computer hardware and software loadsets at CSUMB, go to: https://csumb.edu/it/software Semester/Year: Fall
Spring
Summer
Student’s Name: _________________________________________________________ Student ID: ________________________ Campus: California State University Monterey Bay Please complete this worksheet and return it to your Department of Rehabilitation Counselor. Include all supplies you will need this semester. Substitutions will need to be approved by your Counselor. Completing this form is not a guarantee that these items will be paid for. Need Price Quantity Total $ Item Binder Binder pockets Blue book Calculator Color pen set Color pencils Computer- thumb drive Dividers Erasers Folder Index cards with dividers Hi-liter Mechanical pencil Notebook – 1 subject, spiral Notebook – 5 subject, spiral Notepad Paper – notebook paper 300 sheets Paper – colored Paper – plain white Pen Pencil Pencil pouch Pencil sharpener Planner – week-at-a glance Post-it notes Report covers Ruler White out SUBTOTAL
TAX @ 9.25% TOTAL
Department of Rehabilitation Authorization Worksheet for Books Semester/Year: Fall
Spring
Summer
Student’s Name: __________________________________________________________ Student ID :________________________ Campus: California State University Monterey Bay Bookstore Mgr: Bookstore Phone: Bookstore FAX: Web Address:
Paul Gagne 831.883.1062 831.883.1128 http://csumonterey.bkstore.com
Mail to: CSU Monterey Bay Bookstore 100 Campus Center, Seaside, CA 93955 Email: [email protected]
Please complete this worksheet and return it to your Rehabilitation Counselor. Include all books you will need for this semester. Include course name(s), number(s), title(s) and price(s). Substitutions will need to be approved by your Counselor.
Course Name
Course Number
Book Title
Subtotal Tax @ 9.25% Total
Price
Semester Fees Request for Department of Rehabilitation Consumers 1. Semester/Year: Fall _______
Spring______ Winter _____
Summer _____
Semester start date: ________ End date ________ See Academic Calendar 2. Dept. of Rehabilitation Counselor Name: _____________________________________________
Phone:_________________
3. Student’s Name:_________________________________ Student ID:______________ 4. Registration Fees: No fee required; student receives the following financial aid: PELL, SEOG, EOPS, CARE, or CAL Grants Fee required for_____ X $______ = ______ units Registration Total Student Fee $______ $__________ Parking ($54/sem) $______ (Check payable to: CSUMB Cashier. Indicate that it is for parking and registration.) 5. Books
$______
6. Supplies
$______
Books/Supply Total $__________
(Check payable to: CSUMB Bookstore) 7. Printing at CSUMB (extra if needed): https://csumb.edu/it/printers Printing Total (Check payable to: CSUMB Cashier) $__________ Grand Total $__________ Optional: SDR Staff__________________________________ Date _______________ Send DOR Authorization forms for tuition and fees to:
ATTN: Robin Chase CSUMB Cashier’s Office 100 Campus Center Seaside, CA 93955-8001 Fax: 831/582-3399
Department of Rehabilitation Authorization Worksheet for Supplies For computer hardware and software loadsets at CSUMB, go to: https://csumb.edu/it/software Semester/Year: Fall
Spring
Summer
Student’s Name: _________________________________________________________ Student ID: ________________________ Campus: California State University Monterey Bay Please complete this worksheet and return it to your Department of Rehabilitation Counselor. Include all supplies you will need this semester. Substitutions will need to be approved by your Counselor. Completing this form is not a guarantee that these items will be paid for. Need Price Quantity Total $ Item Binder Binder pockets Blue book Calculator Color pen set Color pencils Computer- thumb drive Dividers Erasers Folder Index cards with dividers Hi-liter Mechanical pencil Notebook – 1 subject, spiral Notebook – 5 subject, spiral Notepad Paper – notebook paper 300 sheets Paper – colored Paper – plain white Pen Pencil Pencil pouch Pencil sharpener Planner – week-at-a glance Post-it notes Report covers Ruler White out SUBTOTAL
TAX @ 9.25% TOTAL
Department of Rehabilitation Authorization Worksheet for Books Semester/Year: Fall
Spring
Summer
Student’s Name: __________________________________________________________ Student ID :________________________ Campus: California State University Monterey Bay Bookstore Mgr: Bookstore Phone: Bookstore FAX: Web Address:
Paul Gagne 831.883.1062 831.883.1128 http://csumonterey.bkstore.com
Mail to: CSU Monterey Bay Bookstore 100 Campus Center, Seaside, CA 93955 Email: [email protected]
Please complete this worksheet and return it to your Rehabilitation Counselor. Include all books you will need for this semester. Include course name(s), number(s), title(s) and price(s). Substitutions will need to be approved by your Counselor.
Course Name
Course Number
Book Title
Subtotal Tax @ 9.25% Total
Price
