Third Party Billing & Enrollment Authorization

This form should only be used to register for non-credit classes offered through Madison College School of Professional and Continuing Education and is only required if an employer requests to be billed directly.

Questions, please call (608) 258-2301, Option 2 or email ace@madisoncollege.edu

Question Title

* Company Information

Organization Name

Street Address

City, State, Zip Code

Organization Representative Name

Organization Representative Phone

Organization Representative Email

Question Title

* If you want to enroll multiple students, please use this linked document and then upload it to this survey. Skip the Student Info Question.

DOC, DOCX file types only.

Choose File

Question Title

* Student PERSONAL Information (Use this if you are only enrolling 1 student). This information must be the personal information for the student, do not use company address or phone numbers.

First Name

Last Name

Date of Birth

Email Address

Student ID # (if known)

Phone

Street Address

City

State

Zip

Please list any former names (this helps if you already have an account in the system).

Question Title

* Please Enter Class Information:

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

Book and/or Material Fees:

Question Title

* Please Enter Class Information:

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

Book and/or Material Fees:

Question Title

* Please Enter Class Information:

5 Digit Class Number:

Course Title:

Class Dates:

Course Fee:

Book and/or Material Fees:

Question Title

* I hereby authorize the above individual to enroll at Madison College Technical College and this company will be responsible for the payment of course fees, including books and materials, as indicated below:

Third Party Billing & Enrollment Authorization

Question Title

* Company Information

Question Title

* If you want to enroll multiple students, please use this linked document and then upload it to this survey. Skip the Student Info Question.

Question Title

* Student PERSONAL Information (Use this if you are only enrolling 1 student). This information must be the personal information for the student, do not use company address or phone numbers.

Question Title

* Please Enter Class Information:

Question Title

* Please Enter Class Information:

Question Title

* Please Enter Class Information:

Question Title

* I hereby authorize the above individual to enroll at Madison College Technical College and this company will be responsible for the payment of course fees, including books and materials, as indicated below:

Question Title

* Total Maximum Charges Authorized

Question Title

* Tax Exempt Information