Student Loan Servicer Designee Form

Business Information

Business Type*

Legal Name*

Trade Name or "DBA"

Business Address 1*

Business Address 2

City*

State*

Digits only:

ZIP *

Digits only:

Phone Number*

Website*

Contact Person Information

First Name*

Last Name*

Address 1*

Address 2

City*

State*

Digits only:

Zip*

Digits only:

Phone Number*

Email*

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