Third Party Authorization

* fields are required

This form is to be completed by Sponsors only. If you are a student and need registration assistance, please contact the Enrollment Center.

If an United States based Company/Agency, with a valid Federal Tax Identification number, issues purchase orders/vouchers/LOI to Cuyahoga Community College, the Third Party Authorization form must be included with the purchase order/voucher/LOI unless the purchase order/voucher/LOI already includes the following information:

Student Information

Full Legal Name
CCC Student Number
Period of Authorization - i.e. (Summer 20xx Semester)
Type of Sponsorship and Amount (Tuition Only; Tuition and Books; Tuition, Books and Supplies; Books only)

Sponsor Information

Name of Sponsor
Address
Billing Address and/or Billing Information
Contact Person
Telephone Number
Email address
Federal Identification Number (Required)
Please submit a W-9 if one has not already been submitted.

Company Name: *

Company Billing Address: *

AP/Invoice Contact Name: *

AP/Invoice Contact Phone : *

AP/Invoice Contact Email: *

Company Contact Email:

Company Contact Name/Title:

Company Contact Phone:

Company Federal Tax ID: *

Purchase Order Number (If using):

Company/Agency Authorizing Name (If different than above):

Additional Information/Instructions:

Semester: *

Non-Credit (Begins July 1 and runs through June 30 of the following year.)
Spring
Summer
Fall

Year: *

Add Attachment (W-9, Purchase Order, Additional students if more than allowed on form.):

Please list the students that the Company/Agency is sponsoring for the term selected above and the maximum amount of charges to be billed. If the Company/Agency is paying a % of costs, please indicate the % to be billed to the Company/Agency. If additional space is needed, please attach a list of students on Company/Agency letterhead.

Note: If you are paying for books and other items not included in the pricing of the courses below, you have the opportunity to set up a separate arrangement with our on-campus Barnes & Noble book stores. Please contact Barnes & Noble for the setup instructions.

Student 1

Student Number (S-Number): *

Student Name: *

Subject and Course Number: *

CRN (if no CRN restriction put “all”): *

Authorized Tuition and Fees

Please select an agreement: *

Yes. I agree to pay for all fees included in the pricing of the course(s) above.
No. I will only pay for the items checked below that are included in the price of the course(s).

I will only pay for the items checked here that are included in the price of the course(s).: *

Tuition
Online books
Materials
Supplemental fees (ex: lab fees, online class fee)
Institutional fee
Other fees (ex: Insurance, Uniform fees, exam/testing fees, etc.)

I will only pay for the items checked above, not to exceed (Please list amount per item): *

Student 2

Student Number (S-Number):

Student Name:

Subject and Course Number:

CRN (if no CRN restriction put “all”):

Authorized Tuition and Fees

Please select an agreement:

Yes. I agree to pay for all fees included in the pricing of the course(s) above.
No. I will only pay for the items checked below that are included in the price of the course(s).

I will only pay for the items checked here that are included in the price of the course(s).: *

Tuition
Online books
Materials
Supplemental fees (ex: lab fees, online class fee)
Institutional fee
Other fees (ex: Insurance, Uniform fees, exam/testing fees, etc.)

I will only pay for the items checked above, not to exceed (Please list amount per item): *

Student 3

Student Number (S-Number):

Student Name:

Subject and Course Number:

CRN (if no CRN restriction put “all”):

Authorized Tuition and Fees

Please select an agreement:

Yes. I agree to pay for all fees included in the pricing of the course(s) above.
No. I will only pay for the items checked below that are included in the price of the course(s).

I will only pay for the items checked here that are included in the price of the course(s).: *

Tuition
Online books
Materials
Supplemental fees (ex: lab fees, online class fee)
Institutional fee
Other fees (ex: Insurance, Uniform fees, exam/testing fees, etc.)

I will only pay for the items checked above, not to exceed (Please list amount per item): *

Student 4

Student Number (S-Number):

Student Name:

Subject and Course Number:

CRN (if no CRN restriction put “all”):

Authorized Tuition and Fees

Please select an agreement:

Yes. I agree to pay for all fees included in the pricing of the course(s) above.
No. I will only pay for the items checked below that are included in the price of the course(s).

I will only pay for the items checked here that are included in the price of the course(s).: *

Tuition
Online books
Materials
Supplemental fees (ex: lab fees, online class fee)
Institutional fee
Other fees (ex: Insurance, Uniform fees, exam/testing fees, etc.)

I will only pay for the items checked above, not to exceed (Please list amount per item): *

Student 5

Student Number (S-Number):

Student Name:

Subject and Course Number:

CRN (if no CRN restriction put “all”):

Authorized Tuition and Fees

Please select an agreement:

Yes. I agree to pay for all fees included in the pricing of the course(s) above.
No. I will only pay for the items checked below that are included in the price of the course(s).

I will only pay for the items checked here that are included in the price of the course(s).: *

Tuition
Online books
Materials
Supplemental fees (ex: lab fees, online class fee)
Institutional fee
Other fees (ex: Insurance, Uniform fees, exam/testing fees, etc.)

I will only pay for the items checked above, not to exceed (Please list amount per item): *

Student 6

Student Number (S-Number):

Student Name:

Subject and Course Number:

CRN (if no CRN restriction put “all”):

Authorized Tuition and Fees

Please select an agreement:

Yes. I agree to pay for all fees included in the pricing of the course(s) above.
No. I will only pay for the items checked below that are included in the price of the course(s).

I will only pay for the items checked here that are included in the price of the course(s).: *

Tuition
Online books
Materials
Supplemental fees (ex: lab fees, online class fee)
Institutional fee
Other fees (ex: Insurance, Uniform fees, exam/testing fees, etc.)

I will only pay for the items checked above, not to exceed (Please list amount per item): *

Terms and Conditions

Pay invoice within 30 days from date of invoice.
The Student's name must differ from Company/Agency Contact signing off on the form.
All College registration and refund policies apply to this contract.
Sponsor is responsible for the student’s tuition, fees and books that were authorized regardless of the status of employment.
Sponsor is responsible for any charges for courses started but not completed (i.e. courses withdrawn from during the semester) or grade(s) received.
Sponsor is responsible for all charges regardless of grade(s) received.
If student grades are required, the student will need to log in to their my Tri-C space to authorize the college to release grades directly to the sponsor.
No student account, financial aid, or academic information will be released without a signed FERPA Waiver authorizing the College to release such information to the Company/Agency.
The College will apply any Federal or State Financial Aid (i.e. PELL, SEOG, OCOG) to the students account prior to billing the Company/Agency. Payment from the Company/Agency will be applied before any institutional or outside scholarships. If this policy conflicts with your Company/Agency policy, please attach a letter of explanation detailing how to apply Company/Agency funds.
Sponsors will be charged at the tuition rate that is applicable to the students’ residency status.
Any authorization accepted in lieu of this form, PO/Voucher/LOI, the sponsor must provide all required above information and agree to the terms and conditions on this form.

All unpaid sponsor balances will be remitted to the Ohio Attorney General's office for collection efforts.

Submitter Name: *

Additional comments:

Please email Bursar@Tri-C.edu for questions about this form.

By clicking Submit you agree to to the terms and conditions stated above.

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