Furman University Monthly Payment Plan Application

Furman University Monthly Payment Plan Application
(please print)

If you had a MPP for this student at Furman through ECSI last year, please indicate you account no.
____________________________________________________________________________________________
Participant date of birth	Participant Soc. Sec. No. (of person to be billed)
____/_______/___________________________________________-______-______________________________
Participant/Person to be billed (Mr/Mrs/Ms/Dr)	(First) (MI) (Last)
____________________________________________________________________________________________
Street Address
____________________________________________________________________________________________
City	State Zip
____________________________________________________________________________________________
Phone: home	work
(____)_____-_________________________________________(____)_____-_____________________________
Student	(First) (MI) (Last)
____________________________________________________________________________________________
Student Social Security Number THIS BOX MUST BE COMPLETED
__________________________-_________________________________-_______________________________
Student will be a (check one):
Freshman Sophomore Junior Senior

Total MPP Amount
This is the TOTAL plan amount,
not the monthly payment amount.

$

from line 3 of worksheet

I have read and I agree to the Monthly Payment Plan Terms and Conditions outlined on the back panel.

__________________________________________	___________________________________
Signature of participant	Date

$75 Annual application fee +	$____________	=	$____________
	Back Payments		Amount enclosed

Your fee and back payments due must be enclosed and cannot be withdrawn through either Direct Debit or Electronic Payment options.

Please detach and mail your applications with your check for the amount due (payable to Furman University c/o Educational Computer Systems, Inc., 181 Montour Run Road, Coraopolis, PA 15108.)

If you are interested in either Direct Debit or Electronic Payment option, make your selection below:

Direct Deposit Option
Yes, I want my monthly payments automatically withdrawn from my checking account.

I have enclosed a separate canceled or voided check for the checking account from which the payments will be withdrawn (this option is not available for savings or brokerage accounts). I have read and hereby agree to the Direct Debit Option Instructions/Terms and Conditions within this brochure. I authorize you to charge my checking account monthly in the amount of my Monthly Payment Plan payment. Please note: Notification of the date of the first direct debit will be made in the Monthly Payment Plan application approval materials (the start date is determined by processing time).

__________________________________________	___________________________________
Signature of Direct Debit participant	Date

Electronic Payment Option
Yes, I want an electronic bill sent to me via e-mail.

If you select this option, ECSI will contact you to establish this process. Please note your fee and back payments must be enclosed and cannot be paid through electronic billing.

__________________________________________	___________________________________
Signature of Electronic Payment participant	Date