OMI College Bound Scholarship Fund Disbursement Request Form
Name:
Address:
City:
State:
Type a question
Email Address:
example@example.com
Best Contact Phone Number:
Beginning date you started at OMl:
/
Month
/
Day
Year
Date
Request Date:
/
Month
/
Day
Year
Date
Request Amount (max $1,400):
Disbursement Information
Name of accredited higher education institution, community college, trade school, or vocational college.
Address:
City:
State:
Zip:
Bursar's Office phone number:
Student Account Number for this Institution
How will these funds be used?
Why do you need funding
Assessment Tests
Intent to Register Deposit
Housing Deposit
Other
Note: You are required to submit a receipt after using funds for the above purposes. Such receipts may be in your Email's inbox. Please upload the receipts below, send or deliver receipts to the OMI Counseling Department.
If other (explain why)
Requestor's Signature:
Date:
/
Month
/
Day
Year
Date
Download and Print PDF
Submit
Should be Empty: