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College of DuPageBilling Agreement • October 4th, 2017
THIRD PARTY BILLING AGREEMENT FORM CONTINUING EDUCATION This form must be submitted at the time of registration and will not be accepted without prior company approval.Please read and complete the form before signing this agreement. Continuing Education Registration Office - Ashley McLaughlin - mclaughl@cod.edu Phone: (630) 942-2209 Fax: (630) 942-3785 Student First Name Student Last Name Birthdate Student Social Security Number or ID# (If known) Street City State Zip Home Phone Work / Cell Phone Male Female Email Address ETHNIC ORIGIN (OPTIONAL) Caucasian Asian/Pacific Hispanic Native American African-American Company Name: Company Billing Address: Company Contact Person: Company Email: Company Phone: Company Authorized Signature & Title: Employer, please check the appropriate lines. Payment is due upon receipt of College of DuPage invoice. Date: Indicate semester enrolled: Fall Spring Summer
