Federal Student Loan Request Form

School Code: E01127

1. For which term(s) will you be requesting a loan, and what is your expected credit-hour enrollment during each term? (Minimum enrollment for a federal student loan is six credit hours.) You may apply for a student loan for up to three consecutive terms at a time (up to four consecutive terms for accelerated programs).

Term

Credit Hours

Term

Credit Hours

Term

Credit Hours

Term

Credit Hours

2. What is your requested loan amount in U.S. dollars ($)?

3. Are you eligible to receive tuition reimbursement or any other form of tuition assistance?

Yes

No

If yes, please provide the amount you expect to receive during your requested loan period.

Tuition Assistance/Reimbursement from Employer:
(Do not exclude taxable amount.)

Veteran's Education Benefits:

Other:

4. Do you plan to purchase or rent a PC during the time frame of this loan?

Yes

No

If yes, please enter the cost and provide a copy of the invoice.

I certify that the information on this form is true and complete to the best of my knowledge. If asked, I agree to provide verification of the information that I have given on this form. I realize that if I do not provide such verification, I may be denied financial aid.

Signature

Date

Permanent Address

City
Region
Postal Code

RIN (9 digits)

Daytime Phone