HOTSPOTS Refferal Form-Fall22-Sum 23

Faculty, thank you for taking the time to fill out this referral form for the student. ITSPD is working toward getting all students that are in dire need of internet access the proper tools. Please make sure that the student you are referring requires and truly needs a hotspot in order to succeed in your course. There is a limited numbers of hotspots available, and the hotspots will be given on a first come, first served referral basis.

Inform student: Hotspots must be returned after each semeter . No renewal are allowed. No Exceptions! (Each semester the student must make a new request).

Approval

Approved Not Approved

IMEI NUMBER

IMEI Phone Number

Hotspot Device - TMOBILE REVVL V +5G

Notes

Equipment Borrowed

Laptop Hotspot Both

Student's Preferred Name*

First Name

Initial (optional)

Last Name

LoLA#*

Student's Personal Cell Phone*

Student's Preferred Email*

Does students have internet at home? If yes, student does not qualify for a Hotspot.*

Yes No

Is the student's internet access intermittent and/or unreliable?*

Yes No

Does the student have a cell phone plan with unlimited data?*

Yes No

Do you agree that student meets the criteria's for the use of a HOTSPOT ?*

Yes No

Instructors Name*

First Name

Last Name

Faculty Signature (By signing you believe that the student should be able to check out a hotspot for internet access for school work.) Once we receive the request, we will notify the student with a consent form. Do not send student to pickup HOTSPOT. *

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Use your mouse or finger to draw your signature above