Summary: Part 1 Identify yourself (mandatory)
Student Number: _______________________Queen's Email: ________________________________________
Student Name: _______________________________________________________________________________
Last Name First Name Initial
Part 2 Setup Pre-Authorized Payment Plan (PPL)
· This method of Payment is available to students in the School of Graduate Studies only
· Attach a void cheque or official document from banking institution (to include: full name of student, bank
number, branch number and account number).
· Fees automatically included in calculation of monthly payments: tuition, student assistance levy, student
activity fees, and UHIP. Please select additional fees you would like to include:
Residence Meal Plan Other: _______________________________
Part 3 Important Information
· This authorization will be in effect for the Fall, Winter, and Spring/Summer terms. Monthly deductions will
continue until the student submits the Change to Pre-Authorized Payment Plan form to discontinue or
payment in full is received*.
· The Pre-Authorized Payment Plan is calculated at the beginning of each term. If there is an addition/change
to fees the remaining monthly payments must be re-calculated manually. Please submit the Change to Pre-
Authorized Payment Plan form to notify the Office of the University Registrar of any changes.
· Deductions take place on the 5th day of each month, for eleven consecutive months (October to August)