Online Programs Enrollment Agreement—Graduate Programs€¦ · QEC-084 (Revised 10/06) 1of3 Initials Online Programs Enrollment Agreement—Graduate Programs This entire form must

QEC-084 (Revised 10/06)

1 of 3

Initials

Online Programs Enrollment Agreement—Graduate ProgramsThis entire form must be completed and submitted as part of your Kaplan University record and should be faxed to your Admissions Advisor’s e-faxnumber. Please print legibly.

Personal Information

NAME: ___________________________________________________________ PREVIOUS NAMES (if applicable): ________________________________

STREET ADDRESS: _______________________________________________________________________________________________________________

CITY: _____________________________________________________________ STATE: ________________________________ ZIP: ______________________

SOCIAL SECURITY #: _______________________________________________ ARE YOU A VETERAN? [ ] YES [ ] NO

HOME TELEPHONE: ________________________________________________ WORK TELEPHONE: _______________________________________________

CELL PHONE: ______________________________________________________ FAX NUMBER: ___________________________________________________

EMAIL ADDRESS 1: _________________________________________________ EMAIL ADDRESS 2: ______________________________________________

KAPLAN EMPLOYEE? [ ] YES [ ] NO DIVISION OF KAPLAN _____________________ WORK LOCATION: __________________________________________

EXPECTED START DATE: _______________________

Postsecondary Education

LAST EDUCATIONAL INSTITUTION: ____________________________________ DATES ATTENDED: _____________________________________________

MAJOR OR SPECIALIZATION: ___________________________________________ DEGREE OBTAINED: ___________________________________________

CITY: ________________________________________________________________ STATE: ________________________ ZIP: ___________________________

EDUCATIONAL INSTITUTION: ___________________________________________ DATES ATTENDED: ____________________________________________


CITY: ________________________________________________________________ STATE: ________________________ ZIP: ___________________________

EDUCATIONAL INSTITUTION: ___________________________________________ DATES ATTENDED: ____________________________________________


CITY: ________________________________________________________________ STATE: ________________________ ZIP: ___________________________

YOUR LAST NAME AT THE TIME YOU COMPLETED YOUR UNDERGRADUATE DEGREE IF DIFFERENT FROM ABOVE: _________________________________

Programs

Please indicate your program and emphasis area or specialization:

Master of Arts in Teaching and LearningEmphasis Area___ Teaching Literacy and Language: Grades K–6___ Teaching Literacy and Language: Grades 6–12___ Teaching Mathematics: Grades K–5___ Teaching Mathematics: Grades 6–8___ Teaching Mathematics: Grades 9–12___ Teaching Science: Grades K–6___ Teaching Science: Grades 6–12___ Teaching Students With Special Needs___ Teaching With Technology

Master of EducationContent Area (Grades 7–12)___ English Language Arts___ Mathematics___ Science___ Social Studies___ Foreign Language___ Visual & Performing Arts

Master of Business AdministrationSpecialization*___ Entrepreneurship___ Finance___ Human Resources Management___ Information Technology___ Management, Communication, and Quality ___ Marketing

Master of Science in Criminal JusticeSpecialization*___ Corrections___ Global Issues in Criminal Justice___ Law___ Leadership/Executive Management___ Policing

*If not indicated, to be determined by the end of the second term.

ONLINE REGISTRAR’S OFFICE550 West Van Buren, 7th FloorChicago, IL 60607Tel: 312.777.6333

ADMISSIONS DEPARTMENT6301 Kaplan University AvenueFort Lauderdale, FL 33309Tel: 866.527.5268 (Toll Free)Tel: 954.515.4700

QEC-084 (Revised 10/06)2 of 3

Initials

Financial

A minimum deposit of $95.00 is required at the time of enrollment to secure your place in class. If you begin classes, the deposit will be credited to yourfirst quarter’s tuition. The deposit is refundable for first-term students only if cancellation of enrollment is received by the University seven days prior to thestart of the term. If eligible, the refund will be processed within 30 days upon receipt of the cancellation notice. All students are required to pay a$______ technology fee per term. The current tuition for your program will be $______ per credit hour. The tuition per credit hour is subject to change.Tuition and fees are subject to change with 30 days of notice.

If applicable, your payment schedule is itemized on the Educational Installment Contract.

Textbooks

Students are responsible for purchasing textbooks and required course materials.

Proof of Bachelor’s Degree

Note to Students: In order to attend a graduate program at Kaplan University, students must have earned a baccalaureate degree from a college or uni-versity accredited by a regional or national accrediting agency recognized by the U.S. Department of Education, and attest to that fact. In signing thisEnrollment Agreement, you certify that you have graduated from such an institution. You will be required to provide official transcripts from this insti-tution by the last calendar day of your first term (second term for MBA). If your official transcript is not received by Kaplan University by this date, youwill not be allowed to start the second term (third term for MBA) and all Title IV financial aid must be refunded to the appropriate source. You willthen be responsible for payment of these funds to Kaplan University. If, for any reason, this attestation is found to be false or untrue, you will be subjectto immediate dismissal from Kaplan University. Furthermore, all Title IV financial aid or any state or institutional funding must be refunded to theappropriate source, and you will be responsible for payment of these funds to the original source or to Kaplan University.

Refund Policy

Applicants not accepted by the University shall be entitled to a refund of all monies paid.

CANCELLATION OF ENROLLMENT AGREEMENT: You may cancel your Enrollment Agreement without any penalty or obligation if requested inwriting and delivered to the University management within three business days after signing the Agreement, excluding Saturday, Sunday, and federal andstate holidays.

NOTICE TO STUDENTS: If you withdraw from the University up through the 60 percent point in any payment period and received federal financialaid in the form of grant or loan funds, federal law requires that the University, and in some cases, you, the student, return funds you did not earn to theU.S. Department of Education. The amount of federal financial aid that you have earned is computed by (1) determining the percentage of the paymentperiod for which federal financial aid was awarded and completed, and (2) multiplying such percentage by the total amount of federal financial aid thatwas, or could have been, disbursed on your behalf for the payment period as of the date you withdrew. After the 60 percent point in the payment period,you will have earned 100 percent of the federal financial aid funds already disbursed to you. This calculation concerning federal financial aid is separateand distinct from the institutional refund policy and may result in your owing additional funds to the University to cover tuition charges previously paidby federal financial aid prior to your withdrawal. If you plan to withdraw from the University, please contact your financial aid or business office todetermine the amount of funds, if any, that must be returned on your behalf.

WITHDRAWAL AFTER COMMENCEMENT OF CLASSES: The effective withdrawal date for a student shall be when any of the following occur:1. The date the student notifies the University of withdrawal or the date of withdrawal, whichever is earlier,2. The beginning date of any term in which a student fails to start classes,3. The first business day following any 21 consecutive calendar days of absences (excluding scheduled breaks),4. The date when the University terminates the student’s enrollment, or5. The date that the student is scheduled to return from a leave of absence and fails to do so.

All refunds due will be made within 30 days of the student’s effective withdrawal date. The last date of actual participation (login) is used in calculatingany refund amount. Students who are continuing or restarting their enrollment at the University are subject to the Kaplan University Refund Policy.Under this policy, the percentages of refundable charges are as follows:

Students Withdrawing Refund

Prior to the first day of the term 100% TuitionDuring the first 6 calendar days of the first term (first-time students only) 100% TuitionDuring the first day through 10% of the term 90% Tuition*After more than 10% and through 25% of the term 50% Tuition*After more than 25% and through 50% of the term 25% Tuition*After more than 50% and through 100% of the term 0% Tuition

*Less $100 Administrative Fee.

The University reserves the right to postpone or change the date or time when any class is offered.

In case of prolonged illness, accident, death in the family, or other circumstances that make it impractical to complete the program, a refund that is rea-sonable and fair to both parties shall be made.

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Additional Conditions

1. The University will not deny admission because of race, color, religion, ancestry, national origin, age, nondisqualifying disability, gender, sexual orientation, marital status, or veteran status.

2. This agreement, its addenda, and its attachments constitute the complete agreement between the University and the student, and no verbal statements or promises will be recognized or enforced.

3. The University does not imply, promise, or guarantee transferability of earned credits to any other institution.4. The University has the right, at its discretion, to make reasonable changes in program content, materials, schedules, sequence of courses in programs,

or locations in the interest of improving the student’s education, or where deemed necessary due to industry changes, academic scheduling, or profes-sional requirements. The University is required to make changes in programs or policies when ongoing federal, state, or accrediting changes affect stu-dents currently in attendance.

5. The University does not provide health services for students.

For Arizona Residents: Any questions or concerns about this school that have not been satisfactorily answered or resolved by the school should be directed to theArizona State Board for Private Postsecondary Education, 1400 West Washington Street, Room 260, Phoenix, AZ 85007, Tel: 602.542.5709, Website:http://azppse.state.az.us.

Signatures

Any controversy or claim arising out of, or relating to, this agreement, or breach thereof, no matter how pleaded or styled, shall be settled by arbitrationin accordance with the Commercial Rules of the American Arbitration Association, and judgment upon the award rendered by the arbitrator(s) may beentered in any court having jurisdiction.

My signature below certifies that I have read the three pages of this Enrollment Agreement and understand and agree to my rights and responsibilities,and that the University’s cancellation and refund policies have been clearly explained to me. I understand that this agreement is a legally bindingagreement, and with my signature certify that I have received and read an exact copy of this agreement and the University Catalog. I further acknowl-edge that no oral statements have been made to me contrary to what is contained in this Enrollment Agreement.

Signature of Applicant X____________________________________________________________________________ Date X__________________________

BUYER’S ACKNOWLEDGEMENTS:

As an authorized official of Kaplan University’s Admissions Department, I have interviewed the applicant and certify that, according to my judgment, theapplicant does meet the admissions requirements and standards of the University, and I recommend acceptance as a student. I further state that I havemade no verbal statements or promises to the applicant contrary to the terms set forth in this Agreement.

Kaplan University Authorized Representative Signature X__________________________________________ Date X______________________________

Name (Please Print) X____________________________________________________________________

I acknowledge and understand that I will be held responsible forthe terms and conditions therein.

A copy of this enrollment agreement may be obtained from myAdmissions Advisor.

An electronic copy of the University Catalog is available atwww.kaplan.edu/ku/downloads.

_________(Please Initial)



X

X

X




Master of Arts in Teaching and Learning Attestation

This form must be completed and submitted as part of your Kaplan University record and should be faxed to your Admissions Advisor’s e-faxnumber. Please print legibly.

Please note: In order to attend Kaplan University, all students must acknowledge, adhere, and attest to the following admissions requirements, poli-cies, and disclosures. The following form should be completed, signed, and faxed to your Admissions Advisor’s e-fax number. This form must becompleted and submitted as part of your Kaplan University record.

I, _______________________________________________, have applied for admission as a Graduate School of Education student at Kaplan University.(NAME)

I understand that one of the requirements for admission to Kaplan University is that I have earned a bachelor’s degree from a college or universityaccredited by a regional or national accrediting agency as recognized by the U.S. Department of Education or that I will have earned a bachelor’sdegree from a college or university accredited by a regional or national accrediting agency as recognized by the U.S. Department of Education priorto the start date of the term I am applying for.

I understand that even if I attest to having the required bachelor’s degree from a college or university accredited by a regional or national accreditingagency as recognized by the U.S. Department of Education, Kaplan University must still receive my official transcripts by the last calendar day of myfirst term. I understand that if my official transcript is not received by Kaplan University by this date, I will not be allowed to start the second term. Iunderstand that all Title IV financial aid must be refunded to the appropriate source, and that I will be responsible for paying all amounts owed toKaplan University directly. I understand that Kaplan University requires that applicants have achieved a minimum GPA of 2.5 on baccalaureatecoursework. Candidates who do not meet this requirement may submit an official transcript indicating a minimum CGPA of 3.0 from a master’sdegree or higher or from at least three graduate courses taken at a regionally or nationally accredited university to be used in lieu of the minimumbachelor's degree CGPA required for admission.

I understand that if my transcripts show that I do not possess the required bachelor’s degree from a college or university accredited by a regional ornational accrediting agency as recognized by the U.S. Department of Education including the required 2.5 GPA on my baccalaureate coursework, any and all financial aid that was disbursed on my behalf must be refunded to the appropriate source, and I will be responsible for payment of these funds to theoriginal source or to Kaplan University.

Students who completed their university education abroad must have earned an equivalent recognized baccalaureate degree. Students must request acourse-by-course translation and evaluation by one of the approved agencies listed by the National Association of Credential Services at the followingwebsite: www.naces.org/members.htm. Official evaluated transcripts of international programs must be received by Kaplan University prior to enrollingin the program. Foreign applicants who possess a bachelor’s degree from an institution in which English was not the primary language must submitofficial TOEFL scores of at least 550 (paper format) or 213 (online format). The Dean has final discretion to approve candidates into a program.

The Master of Arts in Teaching and Learning program is primarily designed for K–12 educators. All activities within the courses are job-embeddedor relate to real-world experiences in the classroom. Specific modifications will be made to the courses to include alternative job-embedded activitiesfor non-practicing educators. Since the program is primarily designed for practicing teachers, the Dean may limit the emphasis area choices availableto non-practicing educators.

The Master of Arts in Teaching and Learning program and curriculum have been designed to provide students with the knowledge and practicalexperience that meet nationally recognized standards for such a degree. However, individual state or school system requirements vary and may changefrom time to time. Thus, Kaplan University makes no representations or warranties as to whether the degree program meets the specific requirementsfor any individual state or school system for certification or pay increase purposes. Kaplan University suggests, and encourages, its students to inde-pendently research the requirements in any state and school system in which they intend to seek certification or a pay increase.

If, for any reason, this attestation is found to be false or untrue, I understand that I will be subject to immediate dismissal from the University, allcredits I have earned will be invalidated, and the University will take all other appropriate actions.

Furthermore, I understand that if this attestation is found to be false or untrue, all Title IV financial aid or any state or institutional financial aidthat was disbursed on my behalf must be refunded to the appropriate source, and that I will be responsible for payment of these funds to the origi-nal source or to Kaplan University, if the University is required to and has refunded such funds on my behalf.

By signing my name below, I attest that the information I have provided is true and correct to the best of my knowledge, and I understand all penal-ties and consequences that I could encounter.

Signature X______________________________________________________________________ Date X_________________________________________

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ATTEST (Revised 12/05)



Master of Business Administration Program Attestation

Please note: In order to attend Kaplan University, all Master of Business Administration (MBA) program students must acknowledge, attest to, andadhere to the following admissions requirements, policies, and disclosures. The following form should be completed, signed, and faxed to yourAdmissions Advisor’s e-fax number. This form must be completed and submitted as part of your Kaplan University record.

Please print legibly.

I, _______________________________________________, have applied for admission as a Graduate School of Management student at Kaplan University.(NAME)

I understand that one of the requirements for admission to the Master of Business Administration (MBA) degree program at Kaplan University is abaccalaureate degree from a regionally accredited institution or an institution accredited by an agency recognized by the U.S. Department ofEducation, with a cumulative grade point average (GPA) of 2.5 or greater.

I understand that even if I attest to having the required cumulative GPA of 2.5, Kaplan University must still receive my official transcripts by the lastcalendar day of my second term (approximately 12 weeks).

I understand that if my official transcript is not received by Kaplan University by the last calendar day of my second term, I will not be allowed to startthe third term. I understand that all Title IV financial aid must be refunded to the appropriate source, and that I will be responsible for paying allamounts owed to Kaplan University directly.

I understand that if my official transcripts reflect a cumulative GPA of less than 2.5 my continued enrollment in the MBA program is subject toapproval by the Dean. Further, justification for acceptance will include a resume detailing related work experience in the field of business. If approval isgranted, I understand that I am required to take and pass KU 500: Foundations of Graduate Learning prior to enrolling in the subsequent term. Ifapproval is not granted, I will be deemed inadmissible and any and all financial aid that was disbursed on my behalf must be refunded to the appropri-ate source, and I will be responsible for payment of the funds to the original source or to Kaplan University.

I understand that in order to be successful in the MBA program I must acquire competencies in economics, accounting, and finance. If my officialtranscripts or my work experience do not reflect such a background, I should acquire those competencies before taking the corresponding graduatecourses. I understand that I may acquire those competencies through the completion of two foundation courses offered by Kaplan University (KU 510: Foundations of Mathematics and Economics and KU 511: Foundations of Accounting and Finance) which are specifically designed to exposestudents to these essential skills. I understand that financial aid does not cover such courses and I will be responsible for payment in full.

I acknowledge that I have received a copy of the Kaplan University Catalog, available at www.kaplan.edu/ku/downloads.

If, for any reason, this attestation is found to be false or untrue, I understand that I will be subject to immediate dismissal from the University, all cred-its I have earned will be invalidated, and the University may take all other appropriate actions.

Furthermore, I understand that if this attestation is found to be false or untrue, all Title IV financial aid or any state or institutional financial aid thatwas disbursed on my behalf must be refunded to the appropriate source, and that I will be responsible for payment of these funds to the originalsource or to Kaplan University if the University is required to and has refunded such funds on my behalf.

By signing my name below, I attest that the information I have provided is true and correct to the best of my knowledge. I understand and agree to therequirements, policies, and disclosures hereunder.

Signature X_______________________________________________________________________ Date X_________________________________________

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Master of Science in Criminal Justice Degree Program Attestation

Please note: In order to attend Kaplan University, all Master of Science in Criminal Justice (MSCJ) program students must acknowledge, attest to,and adhere to the following admissions requirements, policies, and disclosures. The following form should be completed, signed, and faxed toyour Admissions Advisor’s e-fax number. This form must be completed and submitted as part of your Kaplan University record.


I, _______________________________________________, have applied for admission as a Graduate School of Criminal Justice student at Kaplan University.(NAME)

I understand that one of the requirements for admission to the Master of Science in Criminal Justice (MSCJ) degree program at Kaplan University is abaccalaureate degree from a regionally accredited institution or an institution accredited by an agency recognized by the U.S. Department of Education,with a cumulative grade point average (GPA) of 2.5 or greater.

I understand that even if I attest to having the required GPA of 2.5, Kaplan University must still receive my official transcripts by the last calendar dayof my first term.

I understand that if my official transcript is not received by Kaplan University by the last calendar day of my first term, I will not be allowed to startthe second term. I understand that all Title IV financial aid must be refunded to the appropriate source, and that I will be responsible for paying allamounts owed to Kaplan University directly.

I understand that if my official transcripts reflect a GPA of less than 2.5, my continued enrollment in the MSCJ degree program is subject to approvalby the Dean. Further justification for acceptance will include a resume detailing related work experience in the field of criminal justice. If approval isgranted, I understand that I am required to take and pass KU 500: Foundations of Graduate Learning prior to enrolling in the subsequent term. Ifapproval is not granted, I will be deemed inadmissible and any and all financial aid that was disbursed on my behalf must be refunded to the appropri-ate source, and I will be responsible for payment of the funds to the original source or to Kaplan University. Such admission may require the successfulcompletion of a specified number of undergraduate criminal justice courses per the direction of the Dean. I understand that financial aid does notcover these courses and I will be responsible for payment in full.

I understand that I must declare my choice of Thesis Track or Nonthesis Track at the latest by the end of my second term as a graduate student, andthat if I chose to elect a specialization, I must also do so before the end of the second term.

I acknowledge that I have received a copy of the Kaplan University Catalog, available at www.kaplan.edu/ku/downloads.

If, for any reason, this attestation is found to be false or untrue, I understand that I will be subject to immediate dismissal from the University, all cred-its I have earned will be invalidated, and the University may take all other appropriate actions.

Furthermore, I understand that if this attestation is found to be false or untrue, all Title IV financial aid or any state or institutional financial aid thatwas disbursed on my behalf must be refunded to the appropriate source, and that I will be responsible for payment of these funds to the originalsource or to Kaplan University, if the University is required to and has refunded such funds on my behalf.

By signing my name below, I attest that the information I have provided is true and correct to the best of my knowledge. I understand and agree to therequirements, policies, and disclosures hereunder.


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Master of Education Program Attestation

This form must be completed and submitted as part of your Kaplan University record and should be faxed to your Admissions Advisor’s e-fax number.

Please note: In order to attend Kaplan University, all students must acknowledge, adhere, and attest to the following admissions requirements, policies, anddisclosures. The following form should be completed, signed, and faxed to your Admissions Advisor’s e-fax number. This form must be completed and submittedas part of your Kaplan University record.


I, _______________________________________________, have applied for admission as a Graduate School of Education student at Kaplan University.(NAME)

I understand that one of the requirements for admission to Kaplan University is that I have earned a bachelor’s degree from a college or university accredited by aregional or national accrediting agency as recognized by the U.S. Department of Education or that I will have earned a bachelor’s degree from a college or universityaccredited by a regional or national accrediting agency as recognized by the U.S. Department of Education prior to the start date of the term I am applying for.

I understand that even if I attest to having the required bachelor’s degree from a college or university accredited by a regional or national accrediting agency asrecognized by the U.S. Department of Education, Kaplan University must still receive my official transcripts by the last calendar day of my first term. I under-stand that if my official transcript is not received by Kaplan University by this date, I will not be allowed to start the second term. I understand that all Title IVfinancial aid must be refunded to the appropriate source, and that I will be responsible for paying all amounts owed to Kaplan University directly. I understandthat Kaplan University requires that applicants have achieved a minimum cumulative grade point average (CGPA) of 2.5 out of 4.0 on baccalaureate coursework.Candidates who do not meet this requirement may submit an official transcript indicating a minimum CGPA of 3.0 from a master’s degree or higher or from atleast three graduate courses taken at a regionally or nationally accredited university to be used in lieu of the minimum bachelor's degree CGPA required foradmission.

I understand that if my transcripts show that I do not possess the required bachelor’s degree from a college or university accredited by a regional or nationalaccrediting agency as recognized by the U.S. Department of Education, any and all financial aid that was disbursed on my behalf must be refunded to theappropriate source, and I will be responsible for payment of these funds to the original source or to Kaplan University.

Students who completed their university education abroad must have earned an equivalent recognized baccalaureate degree. Students must request acourse-by-course translation and evaluation by one of the approved agencies listed by the National Association of Credential Services at the followingwebsite: www.naces.org/members.htm. Official evaluated transcripts of international programs must be received by Kaplan University prior to enrolling inthe program. Foreign applicants who possess a bachelor’s degree from an institution in which English was not the primary language must submit officialTOEFL scores of at least 550 (paper format) or 213 (online format). The Dean has final discretion to approve candidates into a program.

I understand that candidates not meeting the content requirements in their certification area must take the recommended additional coursework at a college oruniversity of their choice accredited by a regional or national accrediting agency recognized by the U.S. Department of Education prior to student teaching.

I understand that candidates for the Master of Education will be required to complete a minimum of 100 hours of field work (8 hours per week) prior tostudent teaching, and that my schedule must be flexible to accommodate this. Candidates will be required to set up a field experience schedule with fieldsupervisors and practicum teachers prior to the start of each term.

Immunization may be required prior to student teaching.

I understand that candidates for the Master of Education in Iowa will apply for an initial teacher license from the state of Iowa and that a second backgroundcheck will be required at this time.

I understand that I must submit passing scores on the Praxis II test to Kaplan University by Friday of week 5 of the second term. Washington, DC candidatesmust provide proof of passing scores prior to enrollment. In lieu of Praxis tests, Kaplan University may accept passing scores on state examinations requiredfor licensure to teach. For states that require their own exams, candidates must submit passing scores (as determined by their state) on subject area exam(s)by the middle of the second term (as defined above).

I understand that I will be required to devote a full-time schedule during student teaching, and that my schedule must accommodate this.

In order to be in the Master of Education program in Washington, DC, candidates in this region must submit a Form 4 (Application for Provisional Licensurethrough an Alternative Route) with appropriate fee to the Program Director by the end of the first term.

The Master of Education program and curriculum have been designed to provide students with the background and practical experience that meet nationallyrecognized standards for such a degree. However, individual state licensing requirements vary and may change from time to time. Thus, Kaplan University makesno representations or warranties as to whether the degree program meets the specific licensing requirements for any individual state. Kaplan University suggests,and encourages, its students to independently research the licensing requirements in any state in which they intend to seek licensure.

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Revised 07/07

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If, for any reason, this attestation is found to be false or untrue, I understand that I will be subject to immediate dismissal from the University, all credits I haveearned will be invalidated, and the University will take all other appropriate actions.

Furthermore, I understand that if this attestation is found to be false or untrue, all Title IV financial aid or any state or institutional financial aid that was disbursedon my behalf must be refunded to the appropriate source, and that I will be responsible for payment of these funds to the original source or to KaplanUniversity, if the University is required to and has refunded such funds on my behalf.

By signing my name below, I attest that the information I have provided is true and correct to the best of my knowledge, and I understand all penalties andconsequences that I could encounter.



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Statement Regarding Credit BalancesThis form must be completed and submitted as part of your Kaplan University record and should be faxed to your Admissions Advisor’s e-fax number.Please print legibly.

STUDENT’S NAME _______________________________________________ SOCIAL SECURITY # _______________________________________

I am aware that when my current tuition, fees, and other allowable charges have been paid, my account will have a credit balance. I am requesting thatthe balance be handled in the following manner (check all that apply):

The University should retain any existing credit balance on my account to be applied to allowable future charges to assist me in managing thosefunds or to be disbursed to me at my request.

In the event that I do not request the funds prior to leaving school, the University should return the credit balance to the lender as paymenton my student loan.

Student Certification

I understand that the University will retain any interest earned on the credit balance while the school is holding these funds.

I may rescind this authorization to retain the credit balance at any time during the student’s attendance in the program.

I understand that the University may consider this authorization to be in effect throughout the student’s award year or period of enrollment unlessrescinded by the student/parent.

Student X_______________________________________________________________________ Date X__________________________________________

(Signature required)

Documents

Online Programs Enrollment Agreement—Graduate Programs€¦ · QEC-084 (Revised 10/06) 1of3 Initials Online Programs Enrollment Agreement—Graduate Programs This entire form must