EDUCATIONAL TOLL FUND
STUDENT REGISTRATION
DATE: ________________________________________________
NAME: ________________________________________________
STREET ADDRESS (LINE 1): ________________________________________________
STREET ADDRESS/PO BOX (LINE 2): ________________________________________________
CITY, STATE, ZIP CODE: ________________________________________________
PHONE # (To Reach Student): ________________________________________________
EMAIL ADDRESS: ________________________________________________
TYPE OF DEGREE/CERTIFICATE: ________________________________________________
SCHOOL ATTENDED: ________________________________________________
SIGNATURE: ________________________________________________
Please indicate if you prefer your check to be mailed to you or you’d like to pick it up at ESCC:
___________________________________________________________________________
Note: Checks are written approximately once per week, so you may not be able to pick it up the same
day you submit your reimbursement paperwork.
