Textbook Loan Form

Textbook Loan Fund Application

ROBERT STEINBERG MEMORIAL LOAN FUND APPLICATION

Section A: Student Information Section
Name*
First Last
ID #*
Student Email*
Current Address*
Street Address City State ZIP Code
Phone*
Driver's License #*
State Where Issued*
Are You Currently Employed?*
- Yes
- No
Employer/Company*
Work Address*
Street Address City State ZIP Code
Supervisor's Name*
First Last
Work Phone*
References
Give complete names, addresses, and phone numbers.
Reference #1 Name (Relative)*
First Last
Reference #1 Address*
Street Address City State ZIP Code
Reference #1 Phone*
Reference #2 Name (Other)*
First Last
Reference #2 Address*
Street Address City State ZIP Code
Reference #2 Phone*
Textbook Information
To access the Bookstore, please visit: https://www.bkstr.com/palomarstore
Book Title*
ISBN*
Condition*
Book Title
ISBN
Condition
Book Title
ISBN
Condition
Subtotal*
Tax*
Shipping*
Total*
Loan Amount Requested by Student*
Maximum allowed: $250
Please enter a number less than or equal to 250.
*PLEASE NOTE: Due to COVID-19 –ALL books are shipped to you and the cost will be included in this loan. Whenever possible we suggest choosing the cheapest option to allow more money for textbooks.
Certification Statement
I agree to repay the entire invoiced amount incurred from Follett Bookstore within sixty (60) days or no later than the end of the current fiscal year (June 30) whichever comes first. Payments are to be made through the MyPalomar account using credit/debit or ACH. Failure to pay will result in automatic deduction from any financial aid, scholarships, or grants of the authorized funds. Additionally, a Financial Hold is placed on my student records that will not allow me to register for future classes until payment is received. Non-payment may result in legal action in which all expenses will be charged to me.
I have read and agree to these terms.
Signature
Print Name
Date
MM slash DD slash YYYY