Student Application for Services
Name: ________________________________________________________________
Last First MI
Student ID #: __________________________ Phone:__________________________
E-Mail Address: _________________________________________________________
Mailing Address: ________________________________________________________
Are you a transfer student? If so, name of university: _________________________
Please describe your disability: ____________________________________________
________________________________________________________________________
How does your disability affect you in school?
__________________________________________________________________________
What accommodations have you used in the past? How did they help you?
__________________________________________________________________________
__________________________________________________________________________
Who referred you to Disability Support Services?
__________________________________________________________________________
Signature Date
Disability Support Services
Montana State University Billings
Main Campus City College
College of Education, Rm 135 Tech Building, Rm A016
1500 University Dr. 3803 Central Ave
(406) 657-2283 (406) 247-3029
(406) 545-2518 V P (406) 545-1026 V P
(406) 657-1658 fax (406) 247-3014 fax
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