STARBUCKS PARTNER & FAMILY FORM

DIRECTIONS
A. Starbucks Partner completes one form per discount user (self and/or per family member). Form must have original signature(s). B. CityU student submits form to assigned Admission or Student Advisor with current copy of Starbucks Partner redacted paystub. C. Admissions/Student Advisor verifies form complete and forwards documents to Business Office. Starbucks Partner Information Partner Name: Tyler Wilson Contact E-mail: tyler.wilson47@hotmail.com If Yes, Student ID: Program of Study: Starbucks Family Member Information (if applicable) Name: Student ID: Contact Phone: Relationships to Starbucks Partner: Spouse/Domestic Partner Parent Child Sibling Program of Study: Contact E-mail:

Contact Phone: (719) 684-3642 CityU Student? Y N

I hereby certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I acknowledge that the accuracy of the information affects awarding of the Starbucks Partner Discount to the named student account.

Starbucks Partner Signature

Date

Family Member Signature

(if applicable)

Date