Veterans Affairs

Name *

First

Last

Email *

Phone Number + Extension *

I authorize the mentioned student to receive tutoring services within the above mentioned dates. *

Yes

Please read our Tutoring Policy and accept the terms below. By checking the box, you have agreed to the Tutoring Policy Terms and all it entails. For further questions or clarifications, please give us a call at (714) 991-3838.

I accept the terms & conditions in the Tutoring Policy *

I Agree

Tutoring Start Date *

Tutoring End Date *

Number of Tutoring Hours per Week *

Tutoring is contracted at $55 per hour.
If payment method is through Purchase Card then the following applies:
Number of Tutoring Hours per Week cannot exceed a grand total of $2,500 from start date to end date.

Form of Payment *

Tungsten Facility Code: 25160205
Tax Registration Number: 46-485-3628

If using Purchase Card, you must include the contact information of the card holder and your supervisor.

Name, Phone Number, Email of Card Holder *

Name, Phone Number, Email of Supervisor *

Veterans Affairs

Veterans Affairs Referral Form

Counselor Information:

Student Information: