EOP&S Student Request for Additional Support

Please complete the EOP&S/CARE/NextUp/STARS student request for additional support online form and upload supporting documents. All requests will be reviewed and evaluated based on the information submitted. Please allow 5-7 business days for a response.

Name*

First Last

Lancer ID*

8-digit student ID

Phone*

PCC Email*

Enter Email Confirm Email

Course Name*

Instructor Name*

Term*

Fall
Winter
Spring
Summer

Please attach the following documents to your request form:*

Course syllabus, Current class schedule, Any additional supporting documents, Acceptance letter from program (e.g. Nursing, Dental, etc.)

Drop files here or

Are you participating in:

Check all that apply

Other program

Have you met with an EOP&S/CARE/NextUp/STARS Counselor/Staff regarding this request?*

Statement of Need*

Please indicate the service(s) you would like to request:*

Math Calculator (e.g. Statistics course)
Test Prep Book
Test (e.g. TEAS)
Uniform (e.g. Nursing, RadTech, Dental)
Art Supplies
School Supplies
Kit
Other

Please specify kit*

Other service(s)*

Please provide a breakdown of the cost per item(s)*

Use the "+" button to add additional items

Item	Cost

Sub-total*

Grand Total*

Including tax

Vendor Information*

PCC Bookstore
Other

Other Vendor*

Vendor Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Vendor Phone*

Email

This field is for validation purposes and should be left unchanged.