Apply for Tuition Payment Plan

Applicant Information

Borrower *

Borrower
Co-Borrower

Full Name *

First

Middle

Last

LAST 4 DIGITS OF YOUR SOCIAL SECURITY NUMBER *

HOME ADDRESS *

APT. *

CITY *

STATE *

ZIP *

HOW LONG THERE? *

DATE OF BIRTH *

DRIVERS LICENSE NO. *

STATE *

HOME PHONE *

WORK PHONE

CELL PHONE

E-MAIL ADDRESS *

Do you have tuition support that should be added towards the payment plan you are applying for? *

Yes
No

An example of tuition support may be a scholarship from a third party or tuition assistance from an American Job Center.

If yes, how much?

Are you able to make the required down payment for your program? *

Yes
No
I have partial workforce development tuition assistance.

See https://diversenote.mobi/financial-aid for down payment requirement information. Applicants that have partial tuition assistance from a third-party tuition assistance provider (for example, a workforce development office), are not required to pay a down payment.

EMPLOYMENT

EMPLOYER *

HOW LONG THERE? (copy) *

JOB DESCRIPTION *

ADDRESS *

CITY *

STATE *

ZIP *

PREVIOUS EMPLOYER

HOW LONG THERE?

JOB DESCRIPTION

ADDRESS

CITY

STATE *

ZIP

SPOUSE

Full Name

First

Middle

Last

DATE OF BIRTH

SOCIAL SECURITY #

EMPLOYER

HOW LONG THERE?

WORK PHONE

JOB DESCRIPTION

INCOME

Applicant’s monthly take home pay from employer $ *

Other Income (Source)

BANKING

BANK (CHECKING)

BRANCH/ADDRESS

ACCOUNT NUMBER

BANK (SAVINGS)

BRANCH/ADDRESS

ACCOUNT NUMBER

RESIDENCE

LANDLORD OR MORTGAGE HOLDER

MONTHLY RENT OR MORTGAGE PAYMENT $

ADDRESS

CITY

STATE

ZIP

PERSONAL

HAVE YOU OBTAINED CREDIT UNDER A DIFFERENT NAME? *

YES
NO

HAVE YOU EVER DECLARED BANKRUPTCY? *

YES
NO

REFERENCES

REFERENCE 1

Name *

ADDRESS *

CITY *

STATE *

ZIP *

TELEPHONE

REFERENCE 2

Name *

ADDRESS *

CITY *

STATE *

ZIP *

TELEPHONE

REFERENCE 3

Name

ADDRESS

CITY

STATE

ZIP

TELEPHONE

DATE for ADDRESS

Declaration *

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, ACCURATE AND COMPLETE. YOU MAY INVESTIGATE MY CREDIT HISTORY AND FURNISH INFORMATION CONCERNING MYSELF AND THIS NOTE TO ANY PERSON OR FIRM WHO MAY LAWFULLY RECEIVE SUCH INFORMATION.

SIGNATURE OF APPLICANT *

Clear Signature

DATE *

APPLICATION FOR CREDIT

Applicant Information

EMPLOYMENT

SPOUSE

INCOME

BANKING

RESIDENCE

PERSONAL

REFERENCES

REFERENCE 1

REFERENCE 2

REFERENCE 3