MINES PARK HOUSING



CSM TELECOMMUNICATIONS
DISCONNECT AND CHECK-OUT SHEET


NAME (Please Print)_______________________________________________________________



Last Name

First Name

STUDENT ID# ________________________________________PHONE#___________________

MINES PARK UNIT # __________________________________



Please put an “X” next to the services provided to you by Telecommunications:


TELEPHONE SERVICE (monthly base charges)

In order for Telecommunications to transfer base charges from your account to another
persons account, you must have that person fill out a Telephone Services Request Form
(available on the web: http://www.mines.edu/academic/computer/telecom/student-serv.shtml and
present that form along with this one when checking out. Forms are available in our office.




LONG DISTANCE – FINAL BILLING ADDRESS

Street: _____________________

City: ________________________State: ________________Zip: _____________



PLEASE DISCONNECT SERVICES ON: ____________________








Date

STUDENTS ARE RESPONSIBLE FOR ALL CHARGES UNTIL A DISCONNECT / CHECK-OUT SHEET HAS BEEN
FILLED OUT AND DELIVERED TO TELECOMMUNICATIONS.


____________________________________________________
__________________________________
STUDENT SIGNATURE




DATE


CSM Academic Computing & Networking
Telecommunications Office
1650 Arapahoe Street (CTLM Building, Rm 256, NE Corner)

Phone: 303-273-3122 (local) or 1-800-446-9488
Web site: http://www.mines.edu/academic/computer/telecom/student-serv.shtml