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If you do not wish to file the application on-line, please complete this paper application, print and mail this application and the worksheet to: ECSI, 181 Montour Run Road, Coraopolis, PA 15108.

Student Information
 
Social Security Number: __________________________________________________
 
Name (First, Middle Initial, Last): __________________________________________________
 
Address 1: __________________________________________________
 
Address 2: __________________________________________________
 
City, State, Zip: __________________________________________________
 
Email: __________________________________________________
 
Home Phone: __________________________________________________
 
Work Phone: __________________________________________________
 
Fax Phone: __________________________________________________
 
Cell Phone: __________________________________________________
 

Person Financially Responsible
 
Social Security Number: __________________________________________________
 
Name (First, Middle Initial, Last): __________________________________________________
 
Address 1: __________________________________________________
 
Address 2: __________________________________________________
 
City, State, Zip: __________________________________________________
 
Email: __________________________________________________
 
Home Phone: __________________________________________________
 
Work Phone: __________________________________________________
 
Fax Phone: __________________________________________________
 
Cell Phone: __________________________________________________
 

Payment Plan Totals
 
Total Amount to Finance: _______________________ (From Section 4 of Worksheet.)
 
Number of Months: _______________________ (Based on TPP plan you are choosing. See the Brochure for more details.)
 
Monthly Payment Amount: _______________________ (Total Amount to Fincance divided by Number of Months)
 
Application Fee: $45.00  
 
Amount Due Now: _______________________ (Monthly Payment Amount plus Application Fee)
 

Signatures
 
Student Signature: __________________________________________
 
Person Financially Responsible Signature: __________________________________________
 
Date: __________________________________________