Fillable Requester's (HawaiiCC Employee) Contact Information (Hawaii Community College)

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Requester's (HawaiiCC Employee) Contact Information (Hawaii Community College)

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If not, please provide facilitator information below:
Printed Name
Date
Recipient's Information
Funds Requested for Program specific practical experience in which semester?
Fall Spring Summer Year: ______________
Last Name:
UH ID#:
Phone Number:
Email Address:
First Name:
Department:
Course/Program associated with request:
Last Name:
Funded requests will provide financial assistance to students participating in non-paid CVE/Practicum/Internship
placements that provide program curriculum-specific practical work experience. Funds shall be used but not limited
to costs associated with participation in an experiential learning faculty placement.
Requester's (HawaiiCC Employee) Contact Information
Please complete all areas, so we may reach you promptly.
Faculty CVE/Practicum/Internship Support Funding Request
Last Name:
First Name:
Email Address:
Phone Number:
Title (e.g. Faculty, Lecturer, Dean, etc.):
First Name:
Email Address:
Phone Number:
Title (e.g. Faculty, Lecturer, Dean, etc.):
Does the request fit the funding guidelines?
See Guidelines
The facilitator is responsible to notifty the Financial Aid office as soon as they are
aware that the recipient has stopped participating in the experiential learning
placement, to stop future funding disbursements. Will you accept this
responsibility?
Is intended recipient a registered HawaiiCC student in a declared certificate or
degree program?
Are you the facilitator of the placement for evaluation and payment processing?
Responsible Facilitator
YES NO
YES
YES
NO
NO
YES
NO
View Guidelines
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signature
click to edit
Funding request is for?
Printed Name
Date
Printed Name
Date
Printed Name
Date
Printed Name
Date
Printed Name Date
Email this approved form to Financial Aid for processing.
Printed Name
DateProcessed
Total Award Amount to be disbursed according to
above information:
Emailed Date:
Funding will be awarded/paid via Banner Financial Aid portal, and if receiving a Pell Grant, the award may affect
the student's unmet need. Students should check with their Financial Aid Advisor prior to accepting an award.
Funds will be disbursed according to the below timeline:
• First disbursement immediately upon receipt of approved funding request
• Second disbursment at midterm
• Final disbursment paid two weeks to the end of the semester
1 credit award at $200 to complete required practical experience hours. Paid in three
disbursements of $50/$50/$100. Enter required hours for one credit:
2 credits award at $400 to complete required practical experience hours. Paid in three
disbursements of $100/$100/$200. Enter required hours for two credits:
3 credits award at $600 to complete required practical experience hours. Paid in three
equal disbursements of $200 each. Enter required hours for Three credits:
Designee
Funded Date:
Notification emailed to
Faculty Facilitator Date:
APPROVALS: (only one required)
Vice Chancellor for Learning
Facilitator please upload a copy of the Internship Learning Contract or
CVE/Practicum Training Agreement.
Chancellor
Division or Department Chair
Dean
* FA representative - Please email fully executed form back to designee that submitted form to
Financial Aid for processing in Banner.
Processed by Financial Aid
Financial Aid Advisor
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Requester's (HawaiiCC Employee) Contact Information (Hawaii Community College)

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Completed 25 July 2020

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