Third party Billing Agreement

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Third Party Billing Agreement

Third Party Billing Agreement Information

The Billing agreement information must be submitted to Lakeshore College. Lakeshore College will invoice the Company/Agency and payment is due upon receipt. For other questions email studentbilling@gotoltc.edu.

Company Name

Date of Agreement

Billing Address

City

State

ZIP Code

Company Phone Number

Company Purchase Order Number

Authorizing Company Official

Company Offiicial's Email:

Course Title

5 digit class number

Class Start date

Class Title 1

Class Number 1

Class Start Date 1

Class Title 2

Class Number 2

Class Start Date 2

Class Title 3

Class Number 3

Class Start Date 3

Class Title 4

Class Number 4

Class Start Date 4

Student ID (If applicable)

Name

Birthdate (is required) if not given no regisration will be done.

Student ID 1

First Name:

Last Name:

Brithdate #1

Student ID 2

First Name:

Last Name:

Brithdate #2

Student ID 3

First Name:

Last Name:

Brithdate #3

Student Id 4

First Name:

Last Name:

Birthdate #4

Student Id 5

First Name:

Last Name:

Birthdate #5

Student Id 6

First Name:

Last Name:

Birthdate #6

Student Id 7

First Name:

Last Name:

Birthdate #7

Student Id 8

First Name:

Last Name:

Birthdate #8

Please write "all" if paying in full. If you are only funding a portion of the tuition or books please note that as well.

Tuition amount

Book Amount

Supply Amount

Other Instructions (App Fees, Testing Fees, Bid Fees, any other items you are covering or special instructions please specify.

Other comments

Other comments 2

Cancellations:
Class is dropped on or before the first day of class refund will be 100%
99-90% time remaining in the class refund will be 80%
89-80% time remaining in the class Refund will be 60%
Attendance record and/or grades do not affect amount due

Direct tuition bill questions to Student Billing : studentbilling@gotoltc.edu or call Amy @ 920.693.1351 or Gwen @ 920.693.1138.
Books are billed seperately by the bookstore. for additional information on books you can call 920.693.1153 and talk to the bookstore manager.

Lakeshore College does not discriminate against protected classes, including but not limited to race, color, national origin, religion, sex, or gender – including sexual orientation, gender identity, gender expression, disability or age in employment, admissions, or its programs or activities. To handle inquiries regarding Lakeshore's nondiscrimination policies, contact the Educational Support Services Manager (students) 920.693.1120, nicole.yang@gotoltc.edu / Executive Director of Human Resources (staff/others) 920.693.1158, marissa.holst@gotoltc.edu. 1290 North Avenue, Cleveland, WI 53015. TTY 711 gotoltc.edu/equal-opportunity-statement

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