Preview Invoice Receipt

Graduate Student Financial Services

Invoice/Receipt Request

TUITION

2015-2016

APU ID#: _______________________________ Academic Program: _______________________________________

Name: ___________________________________ ____________________________________________ _______

Last First M.I.

Cell Phone (_________)___________-____________ Non-APU e-mail: ______________________________________

Please fill out all areas of the form below:

 This request must be completed for each term as needed.

 Please scan and email this completed form to your assigned Student Account Counselor. You may also mail or fax it

to the Graduate SFS Office: Azusa Pacific University  Graduate and Professional Center: SFS  P.O. Box 7000

 Azusa, CA  91702  Fax: 626-815-4545

A. Invoice/Receipt Term (Select One):  Summer B 2015  Fall 2015  Spring 2016  Summer 2016

B. Reason for my request:

 Company Reimbursement: __________________________________________________(Name of Company)

 Outside Scholarship Agency: _______________________________________________(Name of Scholarship)

 Other:____________________________________________________________________________________

 Relationship:  Family Member  Company  Trust in Family Name  Other ____________________

C. Reporting: Are you receiving any Federal Financial Aid (Federal Direct Subsidized/Unsubsidized Loans, PLUS

Loans, PELL Grant) during the 2015-2016 year?

NO  YES 

Summer B: _________ Fall: __________ Spring: __________ Summer: ___________

D. Additional information required: By default your invoice/receipt will include: Term, Classes, Units, and

Tuition Cost. Please select any other required information from the list below.

 Fees

 Grades

 Social Security Number (SSN)

 Other information required: _________________________________________________________________

E. Invoice/Receipt Delivery:

 Mail to: _________________________________________________________________________________

Street City State Zip

 Fax to: ( ) _______ - _____________

 Email to: ________________________________________________________________________________

 Hold for Pickup (your counselor will notify you when your invoice is ready)

I understand that if for any reason my third party does not make payment to APU, I am responsible for any charges incurred by my

enrollment at Azusa Pacific University. I realize that if my account becomes delinquent, this may have a negative impact on my credit

profile. By signing this form, I also authorize APU to release my academic and financial records as requested; I understand that my social

security number will be listed on my academic record.

______/______/______

Student Signature (Required – No electronic signature accepted)

Date

Last Updated: 3/10/15

Please list the expected value per term of all company reimbursements, scholarships, grants,

or any other outside aid you will receive during the 2015-2016 year. Per federal regulations,

you must report all outside resources when receiving federal financial aid:

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