Signature Card

Lynchburg College Account
Signature Card

Student Account Holder's Signature:______________________________________

Print Student Account Holder's Name:_____________________________________

Student Account Holder's Date of Birth:____________________________________
(This information is kept confidential and secure.) (mm/dd/yyyy)

Account Authorizer's Signature:__________________________________________

Print Name of Account Authorizer:________________________________________

Date:__________________

Email if you would like to be notified of account activation: _____________________________________

Please print out, complete and return to:
Email: CampusStore@lynchburg.edu
Fax: 434.544.8243
Mail: Lynchburg College Campus Store
         1501 Lakeside Drive
          Lynchburg, VA 24501