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 Date (required) Day12345678910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year20272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Type the characters (required) This field should be left blank SendPlease wait... Powered by Quform (unlicensed)