Page 1 of 1
 
 
 
Disability Support Services
Adaptive Equipment Authorization

   
1.
 
   
2.
 
   
3.
 
   
4.
 
   
5.
 
   
6.
 
   
  Please Note Equipment Replacement Cost:

4 track tape player$100.00
CD player$200.00
Listening Headphones$200.00
Automatic Door Opener$20.00
Microcassette Recorder$40.00



Student will be expected to pay the replacement cost of any equipment not returned to Disability Support Services at the end of the semester.
   
7.
Do not fill out this section online.
 

 

 

 

 

 

 

 

 

 
   
8.
To be signed upon receipt of adaptive equipment
 
   
9.
DSS Office use only.
 
   
 
 
 
 Done  Cancel   


© Copyright Midwestern State University