Complete form and return to:

Duquesne University Checks will be ready on Fridays

Room 208, Administration Building Between 12:00 and 3:30.

Pittsburgh, PA 15282 Please Allow at least 2 weeks for processing

REFUND CANNOT BE PROCESSED WITHOUT STUDENT SIGNATURE.

NAME: ____________________________________ ____________________________

Last First                                   Account Number

ADDRESS: ________________________________________________________________

________________________________________ ________________________________

City State Zip Code Telephone Number

Amount of Request: $___________________

Reason for Credit Balance: ____________________________________________________

I understand that any future changes in my course schedule or financial aid package could result in a balance due the University.

STUDENT SIGNATURE: _________________________________ DATE: ____________

I authorize Duquesne University to apply any financial aid I receive, including all federal sources, toward charges assessed to my student account. Duquesne University may continue to apply my student aid funds for this purpose until I rescind my authorization.

STUDENT SIGNATURE: _________________________________ DATE: ____________

To Be Completed if Payee is Other Than Student:

Payee's Name:______________________________________________________________

Address: ___________________________________________________________________

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Refund Approved: ________ Date Approved: _________ Refund Amount: $____________

Voucher #: _____________ Vendor #: ________________ Due Date: __________________

Comment: I SUCHA