Please send completed form to the Office of Student Finance, SSC 150
Course Number (e.g. 5300)
Effective Date or Term Course Fee Amount
□ Add New Fee □ Remove Fee
□ Reduce Fee □ Increase Fee
Description of services provided by this Fee: List Applicable TEC
Estimate dollars to be spent in each category (e.g. handouts -$435, wages $3,200, benefits $501).
For Office Use Only
Entered by __________ Date Entered _____________
University of North Texas Health Science Center
Office of Student Finance, SSC 150
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2699
(817) 735-2026/ Fax (817) 735-0677
*Please contact (817) 735-2026 for assistance in completing this form.
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