Technology Referral Form

Please note that the SSS technology is ONLY available for 黑洞社区 Student Services Program (SSS) program active participants. Please check your status with the program before making the request.

Please fill out this form in order to request a laptop or calculator for the semester from the Office of Special Programs (OSP). Laptops or calcuators are reserved on a first-come, first-served basis. Note that this is only a request, and there is no guarantee that a laptop or calculator will be available when OSP receives your request.

Please verify that your contact information is accurate prior to submitting your request. You will be notified by e-mail when the laptop or ipad is ready for pick up.

Please request any one of these: **

Windows Laptop

Graphing Calculator CASIO (FX-9750G)

Apple Ipad

Your Full Name: *

Your My黑洞社区 ID: *

Your Best Phone Number: *

Email Address: *

Semester: *

Summer

Fall

Spring

Academic Year:

Your SSS Academic Advisor: *

Karen Wright

Chelsea Martinez

Grace Ulichnie

Jahanvi Thakkar

Date of Your Last Meeting with your Advisor*A requirement for this technology check-out is that you have an active status with the SSS program. Meeting your SSS advisor will help you to check your status and get additional academic help.