Express Dollars – IT Money Request Form

Name (required)

ID Number (required)

Email (required)

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

IT Store Quote Number

If you received a quote from the IT Store, please enter the quote number above.

I authorize Arkansas State University to apply the following amount from Excess Financial Aid to Express Dollars - IT Money. (required)

Please note: If the amount requested is greater than Excess Financial Aid available, the amount requested for Express Dollars - IT Money will be reduced to the amount available.

Upon submission of this form, the undersigned hereby opens an Express Dollars - IT Money Account and agrees to be bound by all the terms and conditions set forth in the Disclosure Statement. (1) I understand that this can only be used at the ASU-Jonesboro IT Store. (2) Financial Aid is applied to student accounts based on the number of hours registered. (3) I understand that if the amount of Financial Aid disbursed does not pay my account in full, including the amount for Express Dollars - IT Money, I will be responsible for the balance. (required)

Full Name

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Express Dollars – IT Money Request Form

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