STUDENT NAME: ____________________________________________ __________________
Last Name First MI
DIRECTIONS: Complete Sections 1 and 2 and return this form to the Office of Financial Aid.
Note: Authorizations are only collected once. Should you wish to rescind any Authorization, you may
do so by completing another Authorization Form.
SECTION 1: AUTHORIZATIONS (Check ‘YES’ or ‘NO’ to each question listed below)
Do you authorize the use of your financial aid to pay other educationally-related charges?
(i.e. library fines, lab fines, parking tickets) YES NO
Do you authorize the use of your financial aid to pay other prior-year educationally related
charges up to a maximum of $200.00? (Financial Aid funds will be used to pay the current
term’s charges first before being applied to a prior year’s charges). YES NO
SECTION 2: CERTIFICATION STATEMENT
Read and Sign)
By signing below, I acknowledge I have read and understand the following Rights and Responsibilities:
• It is my responsibility to either pay or make payment arrangements to satisfy all of my Purdue
University Northwest debts, which may exceed my financial aid, on or before the respective
payment deadline date each semester/term as published in the Schedule of Classes bulletin.
• I understand that these Authorizations will cover the entire period that I am enrolled at Purdue
University Northwest and that I can modify or rescind any one or both of these Authorizations at
any time by contacting the Office of Financial Aid.
• I understand that my signature on this Authorization Form incurs the same liability as my
endorsement on a bank check.
Student Signature Date
Office Use only – RRAAREQ: ____ AUTHNI ____ AUTHPY
(G): Authorization Granted (YES)
(U): Authorization Not Granted (NO)
2200 169th Street * Hammond, IN
(21 9))) 989-2301 * FAX: (219) 989-2141
1401 S. U.S. Hwy. 421 * Westville, IN 46391
(219) 785-5460 * FAX: (219) 785-5653
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