Billing Statement Request - Georgia Institute of Technology

Billing Statement Request
Georgia Institute of Technology
Bursar’s Office, Atlanta, GA 30332-0255
bursar.ask@business.gatech.edu, Fax 404-894-5536
Please fill out the form completely and be sure to include your signature.
You may fax, mail, or scan/email the form back to our office. Please allow up
to 3 business days for the request to be processed.
********************************************************
PERSONAL INFORMATION
Print Name:
PRINT NAME AS IT APPEARS ON GEORGIA TECH RECORDS
GT ID #:
Phone Number:
Email Address:
Semester(s) to be included:
Billing Statement Order Information
_____ Will pick-up at the Bursar’s Office
_____ Mail to _____________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_____ Other (please explain) __________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Student’s Printed Name
S t u d e n t ’ s S i g n a t u r e D a t e
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