PBI FUNDS REQUEST FORM
Requestor:
Date:
Contact Information: Phone: Email:
Department:
Position:
Item(s) Requested:
Amount Requested: $
**Copy of quote must be attached**
Educational Purpose:
Please return this completed request with a copy of the quote to the Student Success
Initiative Director @ ljohnson@msdelta.edu. Requests without a quote may be returned.
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Approved ___________ Disapproved ________
Signatures:
Department Chair ______________________________
V.P. of Instruction _______________________________
V.P. of Student Services ___________________________
Student Success Initiative Director ________________________________
Student Success Initiative Administrator ___________________________
Mississippi Delta Community College does not discriminate on the basis of age, race, color, national origin,
religion, sex, sexual orientation, gender identity or expression, physical or mental disability, pregnancy, or veteran
status in its educational programs and activities or in its employment practices. The following person has been
designated to handle inquiries regarding the non-discrimination policies: Steven J. Jones, Vice President of
Administrative Services, Tanner Hall, Suite 202, P. O. Box 668, Moorhead, MS 38761, 662-246-6304;
EEOC@msdelta.edu.
