Fillable form via email to colleen_duval@pitzer.edu or via fax (Pitzer College)

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form via email to colleen_duval@pitzer.edu or via fax (Pitzer College)

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ACH Credit Balance Refund Authorization Form
This completed authorization form allows Pitzer College the authority to deposit any credit balance refund to
the account below while you are studying abroad. Complete the required information below and return the
form via email to colleen_duval@pitzer.edu or via fax at 909.607.8862. All information should be printed and
an actual signature is required. Please contact Colleen Duval at 909.621.8191 if you have any questions.
Student & Financial Institution Information
__________________________________________________
Student Name
_____________________________
Student ID #
__________________________________________________
Account Holder Name
__________________________________________________
Bank/Credit Union Name
______________________________ ______________________________
Routing # Account #
______________________________
Account Type (Checking/Savings)
______________________________ ______________________________
Bank/Credit Union City Bank/Credit Union State & Zip
__________________________________________ ____________________
Student Signature Date
______________________________
Phone #
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form via email to colleen_duval@pitzer.edu or via fax (Pitzer College)

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Completed 25 August 2020

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