Internet Service Provider (ISP) Reimbursement Form

Learning Coach Name (As it should appear on check)*

First NameLast Name

Learning Coach Email Address*

example@example.com

Scholar(s) Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Phone Number*

Please enter a valid phone number.

Internet Service Provider Name*

Please select each month that you are requesting Internet Service Provider Reimbursement for:*

Total

Please upload bills for each month you a requesting a reimbursement for:

Each family may apply for an Internet Service Reimbursement up to, and not to exceed, $20.00 per month

The entire bill must be attached and clearly show the name and address where service is provided, the month of service (billing period and year), and the detailed cost for the service.

Forms must be submitted for at least three months of service. The cut-off date for qualifying for a month of reimbursement will be the 15th of the month.

For example, if a scholar enrolls before the 15th of the month, his/her Internet connection will qualify for reimbursement for the month. If a scholar enrolls after the 15th of the month, his/her Internet connection will not qualify for reimbursement for the month.

Any missing information will delay receipt of the reimbursement. Typical response time to receive the Internet Service Provider Reimbursement is 4-6 weeks once the IT Department receives the request and after confirmation that all required documentation has been submitted. If you have any questions, please direct them to computers@compasscharters.org.

By signing below, I acknowledge my understanding of the Compass ISP Process.*

Date

850 Hampshire Road, Suite R │ Thousand Oaks, CA 91361