Fillable Third Party Payment Authorization (Flint Hills Technical College)

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Third Party Payment Authorization (Flint Hills Technical College)

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File type: PDF

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Street
BUSINESS OFFICE PHONE: 620.341.1311 BUSINESS OFFICE FAX: 620.343.4797 3301 WEST 18TH AVENUE | EMPORIA, KANSAS 66801
Third Party
Payment Authorization
Company/Organization
Billing Address
Telephone Number email
Semester/Academic Year
We agree to pay all selected charges associated with the student(s) listed below. We
understand the charges for Tuition, Fees, Textbooks and Tools required for the program will
be invoiced to us on a semester basis.
Student Name Tuition Fees Textbooks Tools
Example: John Doe 100% 100% 50% 0%
Company Representive - Print Full Name Date
Company Representative - Signature
PLEASE FAX COMPLETED FORM TO: FHTC Business Ofce at 620-343-4797 or
EMAIL COMPLETED PDF TO: businessofce@fhtc.edu
City, ST Zip Code
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Third Party Payment Authorization (Flint Hills Technical College)

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Completed 3 February 2021

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