3
rd
Party Tuition Authorization
D
ate: _____________________
To Whom It May Concern:
P
lease bill __________________________________________________________________________ for
the students enrolled in the class listed below.
C
lass Title: ___________________________
CRN# (s): _______ ________ _______ _______ _______
Semester: (circle one) Fall Spring Summer Year: ___________
Students Name w/middle initial Birthdate or Last four of SS# Tuition only Pay all charges
(Y or N) (Y or N)
1.
__________________________ ______________________ ________ _______
2.__________________________ ______________________ ________ _______
3.__________________________ ______________________ ________ _______
4.__________________________ ______________________ ________ _______
5.__________________________ ______________________ ________ _______
6.__________________________ ______________________ ________ _______
7.__________________________ ______________________ ________ _______
8.__________________________ ______________________ ________ _______
9.__________________________ ______________________ ________ _______
10._________________________ ______________________ ________ _______
Billing/Invoice Information:
E
ntity name: ________________________________________________
Address: ________________________________________________
City, State, zip:________________________________________________
Name of contact person: ________________________________________
Phone number: ( ) ______________
Email Address: _______________________________________________
Sincerely,
(signature of representative of entity/company)
click to sign
signature
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