MAIN WEBSITE
Student Authorization Form
Students Receiving Federal Pell Grants and Federal Direct Loans
School NameRequired Entry
Student NameRequired Entry
SSN#Required Entry
ELECTRONIC FUNDS TRANSFER
I acknowledge that my financial aid funds will be disbursed via electronic funds transfer to the institution and be credited to my student account on a quarter by quarter basis.
*My e-signature below certifies that I have read, understood, and agreed.
Electronic SignatureRequired Entry
DateRequired Entry
AUTHORIZATION TO CREDIT TITLE IV FUNDS TO NON-INSTITUTE CHARGES
I authorize the institution to apply Title IV financial aid funds towards any educational related charges including training materials and non-institutional charges, such as certification exams. I understand that I may cancel or modify this authorization at any time and receive monies due me in full within 14 days of the cancellation.
*My e-signature below certifies that I have read, understood, and agreed.
Electronic SignatureRequired Entry
DateRequired Entry
AUTHORIZATION TO HOLD TITLE IV FUNDS FOR ADDITIONAL CHARGES
A Title IV credit balance occurs when the combined sum of credited Title IV funds exceeds the student's allowable institutional costs (that is, tuition, registration, training materials and lab fees, as well as other costs toward which the student has authorized the institution to apply Title IV funds such as certification exams).
I understand that once my tuition and fee charges have been paid for the quarter, my account may have a credit balance. I authorize the institution to retain any credit balance created by Title IV funds, within a term, in account to pay for any future educational-related charges that may be incurred during the academic year.
*My e-signature below certifies that I have read, understood, and agreed.
Electronic SignatureRequired Entry
DateRequired Entry
AUTHORIZATION TO HOLD CREDIT BALANCE
If federal financial aid funds are available in excess of my allowable charges, I understand that this is a credit balance and authorize retention of the credit balance on my account for future disbursement to me as funds for living expenses. I understand that I may cancel or modify this authorization at any time and receive the funds due me in full within 14 days of the cancellation.
*My e-signature below certifies that I have read, understood, and agreed.
Electronic SignatureRequired Entry
DateRequired Entry
Upon GRADUATION or WITHDRAWL, I request the institution to return any remaining credit balance to:
*My e-signature below certifies that I have read, understood, and agreed.
Must select oneRequired Entry
Electronic SignatureRequired Entry
DateRequired Entry
AUTHORIZATION TO APPLY TITLE IV FUNDS TO PRIOR-YEAR CHARGES
I authorize the institution to use up to $200.00 of my current credit balance to pay for prior-year charges.
*My e-signature below certifies that I have read, understood, and agreed.
Eletronic SignatureRequired Entry
DateRequired Entry

Submit
Allied Health Institute • All Rights Reserved • Copyright© 2011