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Fund Request Form

Must be completed prior to activity engagement

*All fields required

Personal Information

First name:

Last name:

Address:

City:

State:

ZIP code:

Cell phone number:

Email:

Cluster number:

I am a:

Request Information

Amount of funds requested:

Funds are to be used solely for expenses incurred as a result of PAM mentor/mentee activities. Briefly describe the use of the funds requested:

Your submission of this form is considered a signature, certifying that all information is accurate, and that the requested funds will not be used for personal expenditures. Furthermore, should you NOT return receipts and monies within a two-week period upon receipt of funds, your submission certifies that you will be in violation of the University's Honor Code and that appropriate steps will be taken accordingly.