BLUE RIDGE COMMUNITY COLLEGE
THIRD PARTY/EMPLOYER CONTRACT INFORMATION
MAILING ADDRESS: PO BOX 80; WEYERS CAVE, VA 24486-0080
FAX: 540-234-8189; PHONE: 540-453-2529; email: rexrodea@brcc.edu --Agnes Rexrode
Student Name: Student ID#:
ORGANIZATION TYPE: _business, _non-profit, _school, _other
PROPRIETORSHIP _fed gov./state gov.,__local gov.__sole proprietorship__private corp.__ other
ORGANIZATION NAME
FEDERAL ID #
CONTACT NAME
JOB TITLE
PHONE EMAIL
BILLING ADDRESS
CITY STATE ZIP
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CONTRACT INFORMATION
SEMESTER___________________________________________________________________________
CONTRACT MAX AMOUNT ($ OR %) TUITION BOOKS
* A new Third Party/Employer contract must be submitted each semester
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I have agreed that the sponsoring agent will be responsible for payment of tuition and fees on my behalf.
However, in the event the sponsoring agent declines payment for any reason, I agree to assume full
responsibility for all related tuition and fees. It is further understood that until all debt to the College is
satisfied, all future student services, including registration, will be denied.
STUDENT SIGNATURE DATE
SPONSOR/EMPLOYER SIGNATURE DATE
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