Disability Services Intake Form

Online Payments Portal

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Online Payments
Are you a current student?*
Faulkner Student ID Number*
Enter ID Number
######*
Confirm ID Number
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Personal Phone*
Work Phone
Email*
Payment Information
Payment Description*
Social Security Number*
Date of Citation*
MM slash DD slash YYYY
License Plate Number*
Location of Violation*
Date of Citation*
MM slash DD slash YYYY
License Plate Number*
Location of Violation*
Report Number*
Please select your status*
- New student/transfer student
- Returning student
Quantity of Transcripts Requested @ $30/ea.*
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Would you like to put down the payment for your tool kit today and have your equipment by the first day of class?*
This will save you 3% percent fee at a later date. This tool kit is mandatory.
Tool Kit Deposit*
Price:
This will be added to the $500 DPT Deposit.
NOTE: Not paying for the mandatory tool kit with your DPT Deposit will result in a 3% convenience fee.

To pay for your Tool Kit at a later date, return to this Payment Portal, and pay $110 dollars via the 'Other' payment option.
Name of Child in Pre-K*
First Name Last Name
Graduation Month
Graduation Month*
Graduation Year*
Please Note: This form does not apply to J.D. or LL.M. graduates. For more information, please refer to J.D. and LL.M. graduation information or email Dean DeBoer (jdeboer@faulkner.edu) any questions.
Note: This fee is non-refundable except in the event that the program fails to receive accreditation.
Other Payment Description*
Law School Organization Name*
Please Note: This is a payment portal only. To complete a transcript request application, visit the Transcript Request section of the Registrar page and follow the instructions.
Please select your deposit amount*
- $200 refundable deposit (until May 1 of entry year)
- $1000
- Other
Amount*

Minimum of $5.00 required.
Other Amount*
3% Convenience Fee
Price: $0.00
3% Convenience Fee
Price: $0.00
Amount*

Please note that if this graduation application payment is late, you will need to pay an additional $50.
How should this be applied?
- Student's trip
- Mission Trip Fund
Please list the student:
3% Convenience Fee
Price: $0.00
Total
$0.00
The graduation application is closed. Please refer to https://faulkner.edu/student-life/registrar/ for more information.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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Disability Services Intake Form

Student and Disability Information

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Online Payments

Payment Information

First Name	Last Name