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Disability Support Services
PO Box 1510
Pembroke, NC 28372
Phone/Voice: 910.521.6695
Fax: 910.521.6891
TTY: 910.521.6490
Email: dss@uncp.edu
Location: D.F. Lowry Building, Room 103
Campus Map
check out materials form
General Information:
Semester/Session:______________________________________
Student's Name: ________________________________________
Banner ID: ____________________________________________
Telephone Number:______________________________________
Address: ______________________________________________
______________________________________________________
______________________________________________________________
Items to be checked out:
Assistive Device
Name of the device(s): __________________________________
_____________________________________________________
Students are responsible for device(s) checked out and will be held liable if failure to return, damage, or loss occurs. I will return the device(s) to DSS at the date (end of semester) that has been specified.
Student Signature ________________________Date __________
DSS Director Signature ____________________Date __________
Date Checked Out ____________
Date Due __________________
Date Returned _______________
Updated: Tuesday, April 26, 2011
© The University of North Carolina at Pembroke
PO Box 1510 Pembroke, NC 28372-1510 • 910.521.6000