Educational Opportunity Program
Online Laptop Reservation


* You must accept the above regulations before continuing.

*First Name :
Middle Name :
*Last Name :
*Mailing Address :

*City :
*State : * Zip Code :
: Phone Number (###-###-####)
: Cell Phone Number
: Fax Number
: Pager/Message Number
: Email Address *
: Alternate Email Address
*Counselor Name :   
*Major :
Minor :
: Grade Level*
 : Enrollment Status*
: Advisement Date (mm/dd/yyyy)
*Have you checked out a laptop before ? Yes No
*Have you ever been placed on probation ? Yes No
*Please explain your need for the laptop :
* Denoted fields are required.