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Department information department name: contact name: phone number
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25.06.2016
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DATE:
STUDENT
INFORMATION
Scholarship/Award
Disbursement
Last Name: First Name: Net ID:
Address
City
State Zip Code
Phone Number
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DEPARTMENT INFORMATION
DEPARTMENT NAME: CONTACT NAME:
PHONE NUMBER:
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:
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SCHOLARSHIP INFORMATION
ACADEMIC YEAR: TOTAL AWARD: $
QUARTER: QUARTER: QUARTER: QUARTER: AMOUNT: $ AMOUNT: $ AMOUNT: $ AMOUNT: $
FUNDING INFORMATION
DONOR NAME (if known): FUND ID & NAME:
VERIFICATION
AND AUTHORIZATION
I have verified that all criteria for this scholarship have been met:
Name: Department Title: Signature for Verification:
Authorization
for Release of Funds
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: D
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Signature for Release of Funds:
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PeopleSoft Chart Field or Ed Foundation Account Number:
Processing (Initials/Date):
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Or
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:
Office of Financial Aid (OFA)
UA Received: Processed: UAO Received: Processed:
SA 3418
Scholarship
Coordinator
(510) 885-2784
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