Courier / Student Information

Please list the FIRST AND LAST names of your designated SCRIP Courier(s)

Click the + to add more names.

SCRIP Account Holder Consent

I understand that I am giving my consent for the above-listed couriers to pick up my FVL SCRIP orders from the date of this form and forward. If I have changes to this consent, I will fill out a new form.

Type your electronic signature below. *

This document is being submitted by the account-holder and is the person whose electronic signature is above. *

Yes

This document must be submitted by the account-holder. If you are not the account-holder, this document is invalid and will not be honored.

Email of person completing form *

Comments or Questions?

Comments, questions, or additional information that needs to be shared.