Third Party Authorization Form - Georgian
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1Office of the Registrar
Office of the Registrar
One Georgian Drive, Barrie, ON L4M 3X9
T: 705.728.1968
GeorgianCollege.ca
Third Party Authorization Form
Section 1 – Student Information
Family Name
First Name
Second Name
Day:
Month:
Year:
Sex:
Female
Male
Date of Birth
House/Apt #
Address
Street
City
Province/State
Postal Code
Country
Section 2 – Person you authorize to receive the funds on your behalf
Beneficiary Name
House/Apt #
Beneficiary Address
Street
City
Province/State
Postal Code
Country
Country Code (
)
Area Code (
) Number
-
Home Telephone
Relation to the student
__________________________________________
___________________________
Student Signature*
Date
*The student signature on this authorization form MUST match with the signature on the passport. A copy of the
signed passport is required to process the refund.
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Parent category: Business