PO Box 7751 Havre, MT 59501 • (406) 265-3776
Revised 7-21-2015 by RMN
Student Application for Disability Accommodation Services
Today’s Date: ________________
Name: ____________________________________ Student ID#:______________________
Last, First MI
Mailing Address: ____________________________ City, State Zip: ____________________
E-Mail Address: _____________________________ Date of Birth: _____________________
Home Phone: _(_____)_______________________ Work/Cell Phone: _(_____)__________
Program of Study: ___________________________ CAS, AAS, AA, AS, BAS, BA, BS, Master’s
(Circle One)
Are you a client of Department of Vocational Rehabilitation? ______Yes _____No
Voc Rehab Counselor’s Name: __________________________________________________
Please describe your disability: _________________________________________________
What auxiliary aids, accommodations, or academic adjustments are necessary in order for you
to obtain equal access to educational programs and activities at MSU-N?
Signature Date
Application is not complete until the school receives adequate documentation of the
I hereby authorize MSU-Northern Disability Services to release copies of my Disability
Documentation to MSU-Northerns Student Support Services (SSS) for the purpose of
enrolling with SSS.
Signature Date