Student Access Services University Housing Accommodations
Name
First Name
Last Name
Banner ID# 900
Email
NMT email will be used for all official correspondents @student.nmt.edu
Phone #
Date of Birth
Campus PO Box #
PO Box # if known
Campus Address
Dorm or Apartment information if known
Student Access Services (SAS) certifies that this student has a disability that requires the following housing accommodations for the Academic Semester or term:
Semester or academic term
#1
Accommodation
#2
Accommodation
#3
Accommodation
#4
Accommodation
#5
Accommodation
#6
Accommodation
Student Signature - By signing below you authorize Student Access Services (SAS) to share the information with the New Mexico Tech Housing and Residential Life Staff for the purpose of securing housing accommodations.
Date
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Month
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Day
Year
Date
Student Access Services Representative Printed Full Name and Title
Student Access Services Signature
Date
/
Month
/
Day
Year
Date
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Should be Empty: