Financial Disclosure Authorization
To be completed and signed by the student.
Name Banner ID
(Please print clearly)
List authorized individuals or companies who you wish to receive your student financial account
information. Return completed form to Student Accounts in Fidel, room 231.
Name Name
Address Address
Phone # Phone #
Name Name
Address Address
Phone # Phone #
Name Name
Address Address
Phone # Phone #
Name Name
Address Address
Phone # Phone #
I hereby authorize New Mexico Institute of Mining and Technology to release any and all information
concerning my student financial account to the above named individual(s).
Signature Date
Revised 12/06/09
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