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Lost/Damaged Equipment

Student ID #*

Answer required for "Student ID #"

Student's First & Last Name*

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Please choose one.*

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$89.00 - Broken/Stolen/Lost Chromebook

$25.00 - Chromebook Charger is Broken or Missing

$40.00 - Lost/Damaged Yondr Pouch

Other:

If you selected "Other Amount," please specify the purpose of your payment.

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Contact Information

First Name*

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Last Name*

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Street Address*

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City*

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Zip/Postal*

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Confirmation Email

Confirmation Email *

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