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Name of Borrower: (Student or Parent) (Last, First MI)

Name of Student: (Last, First MI)

Bucknell ID Number:

Phone:

Email Address of Person Submitting Authorization:

Type of Loan:


Note: A separate Authorization form is needed for each type of loan by the borrower of that loan.

AUTHORIZATION STATEMENT
If the total Title IV, HEA program funds credited to my student account exceeds the amount of tuition, room and board, I authorize Bucknell University to pay other current charges that were incurred at Bucknell for educationally related activities. These charges may include books, supplies, telephone toll charges, etc., which were incurred either before or within 14 days of the credit balance occurring. This authorization is valid for the period during which the student is enrolled at Bucknell University. I understand that I may cancel or modify this authorization at any time.

I authorize Bucknell University as stated in the above Authorization Statement.

Date of Authorization: as of 8/17/09

Additional Comments:

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