TE Change Request Form

TUITION EXPRESS

INFORMATION CHANGE REQUEST FORM

FAX #: 541-858-7008

Instructions: This form is used to make changes to your Tuition Express account. Please complete all sections that apply to the requested changes. Please make sure

an "Authorized Signor" has signed this form to avoid a delay in implementing the requested changes. Certain changes require that a representative of Tuition

Express verify the request via phone. (i.e. certain bank account changes) In the event verbal approval is required, changes will not be completed without verbal

approval.

Name & Title Date

1 W. Main St

Medford OR. 97501

800-338-3884

Current Account. #Current Routing #Bank Name

Existing Bank Information:

New Account. #

New Routing #

Bank Name

New Bank Information:

BANK ACCOUNT CHANGE Please attach a copy of a Voided Check

GLOBAL ACCOUNT LIMIT CHANGE

Current Maximum Limit:

Requested Maximum Limit:

Reason for Increase:

By signing above I hereby state that I have the legal authority to sign on behalf of the center/organization referenced herein. I further authorize Tuition

Express and its representatives to make the requested changes as outlined on this form. I understand and agree to reimburse Tuition Express for any loss

it may incur in instituting the requested changes. I further indemnify and hold harmless, Tuition Express and its officers and employees from any and all

liabilities resulting from the implementation of the requested changes.

Bank Account changes require ONE business day to execute

EMAIL ADDRESS CHANGE

Add Remove

E-Mail Address

By requesting an increase to the Global Maximum Limit the below signed authorized personnel recognizes that the change may increase the monetary risk

exposure of the center.

CENTER APPROVAL

Please update "Add/Remove" e-mail addresses to reflect a list of all e-mail addresses to be used for Tuition Express notifications. Tuition Express is limited

to 100 total characters for all e-mail addresses.

Add Remove

E-Mail Address

Change Request Form_Center v2.0 Revised 05-16

Center Name:

Center Address:

Phone:

City: State: Zip:

Signature:

Additional locations changes apply to:

Reason for Bank Change