Current Class Group

Student ID

Address (Street, City, State, Zip)

Phone Number (999-999-9999)

E-Mail Address (username@somedomain.ext)

For which semester do you need a Statement of Account?
Spring2003Summer2003Fall2003Spring2004Summer2004Fall2004Spring2005Summer2005Fall2005Spring2006Summer2006Fall2006Spring2007Summer2007Fall2007Spring2008Summer2008Fall2008Spring 2009

Reason for Request
Employer Reimbursement
Personal Records
Parent Request
Other -

Credit Hours
I do not need a list of courses and credit hours with my statement
I need a list of courses and credit hours with my statement

Delivery Method
Mail Statement of Account to my home
I will pickup the Statement
Fax to: (999-999-9999)

Additional comments

The information requested below is to be completed by all students requesting a statement of account whether or not they are employed or being company reimbursed.

Are you currently employed?
Yes No

If you are currently employed, complete the following section:

Employer Reimbursement
$ per (Select)SemesterYear

Employer

Employer Address (Street, City, State, Zip)

Employer Phone (999-999-9999)

By Submitting this form, you are authorizing the release of company reimbursement information to DeVry Institute of Technology Student Finance Department upon request