Please print and complete this application, then mail it to:

Heartland ECSI c/o The George Washington University TPP Application
PO Box 1278
Wexford, PA 15090

If you need help completing this form, please contact ECSI toll free at 866-927-1438.

Student Information

Student ID Number:
___________________________________________________________
Name (First MI Last):

 ___________________________________________________________
Address 1:

 ___________________________________________________________
Address 2:

 ___________________________________________________________
City/State/Zip:

 ___________________________________________________________
Email:

 ___________________________________________________________
Home Phone:

 ___________________________________________________________
Work Phone:

 ___________________________________________________________
Fax Phone:

 ___________________________________________________________
Cell Phone:

 ___________________________________________________________

Person Financially Responsible
Name (First MI Last):

 ___________________________________________________________
Address 1:

 ___________________________________________________________
Address 2:

 ___________________________________________________________
City/State/Zip:

 ___________________________________________________________
Email:

 ___________________________________________________________
Home Phone:

 ___________________________________________________________
Work Phone:

 ___________________________________________________________
Fax Phone:

 ___________________________________________________________
Cell Phone:

 ___________________________________________________________

Tuition Payment Plan

Select a plan: Select One
  Description Months Fee Start Date End Date Sign Up By
3 Month Plan (T7M03) 3 $35.00 04/20/2017 06/20/2017 05/01/2017


Student Status

Summer Tuition and Fees: ______________________


Financial Aid:
(as it appears on your award letter. Do not include Work Study.)

If you have questions, please contact the Financial Aid Office at The George Washington University.

Summer Financial Aid: ______________________


Payment Plan Totals
   

Total Tuition and Fees:
______________________ (Tuition amounts from above)
(-) Less Financial Aid:

 ______________________ (Total of all sources of Financial Aid)
Total Amount to Finance:

 ______________________ (Tuition and Fees minus Financial Aid)
Number of Months:

 ______________________ (See Payment Plan Information for selected plan from above)
Monthly Payments:

 ______________________ (Total Amount to Finance divided by number of months in selected plan)
Application / Participation Fee:

 ______________________ (See Payment Plan Information for selected plan from above)
First Payment †:

 ______________________ (Includes months past due and application/participation fee)
† - The application fee is due immediately. If the plan has not yet started, your first monthly payment is not due until the first due date.


Billing and Payment Information
Please sign me up for Electronic Bills
Electronic Bills replace paper bills, provide 100% of the same information, are archived for up to 10 years, and are available within minutes of preparation. When an electronic bill is prepared, you will receive an Email notifying you to return to our web site and review your billing statement.

Complete your payment options below.
Automatic Payments from Checking/Savings

You can make each future payment automatically from your checking or savings account. To do so, please check the box below and fill in the following information. If you are required to make a payment now, you will be given the opportunity to do this after submitting the application.
I would like to sign up for automatic payments
Account Holder Name: __________________________________________
Account Type: Checking Savings
ABA/Routing Number: __________________________________________
Account Number: __________________________________________
I (we) hereby authorize Educational Computer Systems, Inc. to initiate debit entries to my (our) account in the entity named above ("institution"), and I (we) authorize the institution to accept and to debit the amount of such entries to my (our) account. A one-time debit shall be made to cover the application fee and any past due payments. A debit shall be made each month equal to the amount due for that month's payment.