Application Form for Special Education Needs (SEN) Fund The form will take about 10 minutes to complete. Section 1 to be completed by Student – Personal Particulars Name: Admin No: Citizenship: Singaporean/ PR/ NRIC no: Foreigner* Date of birth: Address: Contact number: (H) Contact number: (HP) Email address: School: ASC / BUS / DES / ENG / HSS / IIT * Diploma: Year of study: PFP / 1 / 2 / 3 * Request for AT Devices Support Services Type: Type: Model: Duration: Supporting Documents Statement of diagnosis from medical Recommendation on AT device/support professionals services by medical professional - Required only if item is not listed in Table 1 (Page 2) Section 2 to be completed by SEN Officer – Approved Not Approved In the list of approved items Reason(s): Within student’s allocated fund of $ ___________ Name: Signature: Date: MOE-issued AT devices brought forward from secondary school (if any): AT devices/support services purchased for student Attachments: – Delivery Order / Invoice * MOE’s approval (for items not listed in Table1) Others: _______________________________ Amount of funding disbursed to student for this application (inclusive of GST): $ _______________ disbursed to student till date (inclusive of GST): Total amount of funding $ _______________ as of _______________ (date) Section 3 to be completed by Student (for approved cases only) –
Application Form for Special Education Needs (SEN) Fund The form will take about 10 minutes to complete. Section 1 – to be completed by Student Personal Particulars Name: Admin No: Citizenship: Singaporean/ PR/ Foreigner* NRIC no: Date of birth: Address: Contact number: (H) Contact number: (HP) Email address: School: ASC / BUS / DES / ENG / HSS / IIT * Diploma: Year of study: PFP / 1 / 2 / 3 * Request for AT Devices Type: Model: Support Services Type: Duration: Supporting Documents Statement of diagnosis from medical professionals Recommendation on AT device/support services by medical professional - Required only if item is not listed in Table 1 (Page 2) Section 2 – to be completed by SEN Officer Approved In the list of approved items Within student’s allocated fund of $ ___________ Not Approved Reason(s): Name: Signature: Date: MOE-issued AT devices brought forward from secondary school (if any): AT devices/support services purchased for student – Attachments: Delivery Order / Invoice * MOE’s approval (for items not listed in Table1) Others: _______________________________ Amount of funding disbursed to student for this application (inclusive of GST): $ _______________ Total amount of funding disbursed to student till date (inclusive of GST): $ _______________ as of _______________ (date) Section 3 – to be completed by Student (for approved cases only)
SEN%20Fund%20Application%20Form.docx