Fillable 3 Third Party Authorization Form (Lakeshore Technical College)

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3 Third Party Authorization Form (Lakeshore Technical College)

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Company Name and Billing Address: Date of Agreement:
Company Phone:
Company PO (optional):
Print Name:
Course Title: Class No: Start Date:
Course Title: Class No: Start Date:
Course Title: Class No: Start Date:
Course Title: Class No: Start Date:
Student ID#
(LTC Staff Use)
Name of Student
1
2
3
4
5
6
7
8
Costs Paid by Company:
Tuition: $ Books: $ Supplies: $
Tuition: $ Books: $ Supplies: $
1
2
3
Cancellations:
Class is dropped on or before first day of class Refund 100%
Corp ID:
99-90 % Time remaining in class Refund 80% Course List
89-80% Time remaining in class Refund 60% Contract No:
Less than 80% Time remaining in class Refund 0% Term: Initials
Attendance record and/or grades do not affect amount due Fee Code: Initials
Direct tuition bill questions to Student Billing: studentbilling@gotoltc.edu Amy @ 920-693-1351 or Gwen @ 920-693-1138
Books are billed separately by the bookstore. For additional information call the bookstore at 920.693.1153
Authorizing Company Official Signature:
Lakeshore Technical College
Student Billing Office, 1290 North Ave, Cleveland, WI 53015
THIRD PARTY BILLING AGREEMENT FORM
The Third Party Billing Agreement Form must be submitted to the Registration Office at the time of Registration
Lakeshore Technical College will invoice the Company and payment is due upon receipt.
Fax: 920-693-3561 e-mail: studentbilling@gotoltc.edu
Other Instructions: (App Fees, Testing Fees, Any other please specify)
Birthdate of Student
Or last 4 digits of SS#
For LTC use only
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3 Third Party Authorization Form (Lakeshore Technical College)

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Completed 9 October 2020

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