Third Party Billing Agreement Student's Last Name Student's Id# Student's First Name: Cell Phone #: CU Email: Agency Name: Contact Name: Contact Phone #: I hereby authorize the Office of Business Services at Campbellsville University to invoice my sponsor for the tuition and related charges as specified in the Letter of Intent/Authorization issued by my Third Party Sponsor. Consequently, I agree to and understand the following: (Please read and initial if you agree) I will ensure that the University is provided with a valid authorization letter/voucher from my thirdparty sponsor prior to the beginning of each term to avoid late payment fees and financial holds; If awarded additional assistance for books, I will submit a copy of my bookstore receipt to the Office of Business Services. I understand that if I fail to submit a receipt, my charge will not be invoiced and payment for books will become my responsibility; I am responsible for making timely payments for all charges that are not covered by my sponsor, and will be subject to late payment charges if a payment is not made on time; I will notify the Third-Party Contact Person of any changes to my program, registration, address or sponsor's address; If payment is not received in a timely manner from my sponsor or from me for any charges that are not covered by my sponsor, my account will be placed on hold in keeping with University policy. Consequently, I will not be allowed to register, make changes to an existing registration or receive a diploma or transcript; This agreement does not relieve me from any financial responsibility to Campbellsville University. I am fully liable for charges not paid by my sponsor; Any unpaid charges left on my student account are subject to collection action and collection costs including reasonable attorney's fees and all expenses incurred by Campbellsville University. I understand that this agreement must be completed and signed in order for me to participate in the Third Party Billing Program. I have read and understand this Third Party Billing Agreement and agree to the terms. __________________________________________ Student Signature Third Party Contact Person: Tony Huddleston ______________________________________________ Date 270.789.5385 [email protected]