Questions or problems with this form, please call Bursar's Office at 419.530.5767.

Requestor Information:

Requested by:
Email:
Phone Number:

Comments? (If you require this subcode by a certain date, please enter that here.)

Please provide information for new subcode (* Denotes required field):

* Subcode Description:
* User:
* Charge/Payment:
* FRS Account 1: - -
FRS Account 2: - - (e.g. 9-99999-9999)

or select:
Charge Class:
Memo Flag: (Default = Blank)
Sub Code Type:
SAM Refund:
SAM Aid ID:

 Additional information Required for all CONTRACTS:

Contract Address:

Contract Phone#:
Who is responsible for linking student to contract/waiver?
Phone number for person responsible for linking:

 

 

Tuition:

Select which student level(s) will be covered by this contract/waiver, the default is ALL levels.  If this is not correct, check as many levels as apply.

 

All levels -- Law, Graduate, Graduate - MBA, Pharm D and Undergraduate

Law only

Graduate - MBA only

Pharm D only

Graduate only

Undergraduate Only

Select the specific coverage for this tuition.  Choose one of the following or if none of these apply,  select OTHER, and write description in space below:

 

Tuition (tuition AND Drops - In State, Michigan Reciprocity,  and Out of State)

Tuition Only (no drops) -In State, Michigan Reciprocity,  and Out of State)

Tuition AND drops - In State Only  

Other  -- The coverage for tuition is as follows (please fill in)
General Fee:

Select which student level(s) for GENERAL FEE will be covered by this contract/waiver, tThe default is ALL levels.  If this is not correct, check as many levels as apply.

 

All levels -- Law, Graduate, Graduate - MBA, Pharm D and Undergraduate

Law only

Graduate - MBA only

Pharm D only

Graduate only

Undergraduate Only

Select the specific coverage for GENERAL FEE.  Choose one of the following or if none of these apply,  select OTHER, and write  description in space below.

 

General Fee (General fee AND drops - In State, Michigan Reciprocity,  and Out of State)

General Fee Only - NO DROPS - In State, Michigan Reciprocity,  and Out of State)

General Fee AND drops - In State Only 

Other - The coverage for General Fee is as follows (please fill in)

 

    

Other Fees:

Choose all that apply:

 

Lab Fees

Technology Fees

Engineering Co-Op

ID Card

Matriculation Fee

Parking

Legal Services

Special Service Fee

Other:  (For items not listed, or to clarify choices)

 

 

 

Beginning Term: