Third Party Billing & Enrollment Authorization Survey

Company Information(Required.)

Organization Name

Street Address

City, State, Zip Code

Organization Representative Name

Organization Representative Phone

Organization Representative Email

If you want to enroll multiple students, please use this linked document and then upload it to this survey. Skip the Student Info Question.

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Student PERSONAL Information (Use this if you are only enrolling 1 student). This information must be the personal information for the student, do not use company address or phone numbers.

First Name

Last Name

Date of Birth

Email Address

Student ID # (if known)

Phone

Street Address

City

State

Zip

Please list any former names (this helps if you already have an account in the system).

Please Enter Class Information: Please enter info in each box, use NA if necessary.(Required.)

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

Please Enter Class Information: Please enter info in each box, use NA if necessary.

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

Please Enter Class Information: Please enter info in each box, use NA if necessary.

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

Please Enter Class Information:

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

I hereby authorize the above individual to enroll at Madison College Technical College and this company will be responsible for the payment of course fees, including books and materials, as indicated below:(Required.)

I AGREE

Total Maximum Charges Authorized(Required.)

Tax Exempt Information

Tax Exempt Number

The Family Educational Rights and Privacy Act of 1974 (FERPA) is a federal law designed to protect the confidentiality of your education records. FERPA governs the release and access to these records. Madison College is committed to protecting the privacy of your student records by following FERPA guidelines.(Required.)

I do not foresee needing any private information for my employee.

I may need to ask for private information from my employees regarding their class. Please give this link to your employee Consent for Release of Student Information (PDF). They will need to complete this release form.