Statement of Account Request

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?
Spring2003 Summer2003 Fall2003 Spring2004 Summer2004 Fall2004 Spring2005 Summer2005 Fall2005 Spring2006 Summer2006 Fall2006 Spring2007 Summer2007 Fall2007 Spring2008 Summer2008 Fall2008

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) Semester Year

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