Deferred Payment Plan and Promissory Note Payment Schedule

PROMISSORY NOTE APPLICATIONBanner ID ___________________STUDENTS NAME _____________________________ SSN ________________________BIRTH DATE_____________ DRIVER’S LICENSE # ___________________STATE _____EMPLOYER___________________________ WORK PHONE _ ___________________CITY ______________________ STATE ___________________ ZIP CODE ___________SPOUSE’S NAME ______________________SPOUSE’S EMPLOYER ________________PRESENT ADDRESSPLEASE PROVIDE A CURRENT DELIVERABLE ADDRESSADDRESS _______________________________________________________________CITY ________________________________ STATE _____________ZIP CODE _______PHONE_____________________________ E-MAIL ADDRESS __________________PERMANENT ADDRESS (if different than Present Address)ADDRESS _______________________________________________________________CITY ______________________ STATE ___________________ ZIP CODE __________PHONE ( ) __________________LIST A REFERENCE IN A DIFFERENT HOUSEHOLDNAME ___________________________________________________________________CITY ______________________ STATE ___________________ ZIP CODE ___________PHONE _______________________________________Deferred Payment Plan[1].doc