Furman University Tuition Payment Plan Application
(please print)


If you had a TPP for this student at Furman through ECSI last year, please indicate your 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

Payment Plan (check one):
10 Month Annual Plan 5 Month Fall Plan 4 Month Fall Plan 3 Month Fall Plan 5 Month Spring Plan 4 Month Spring Plan 3 Month Spring Plan


Total TPP 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 Tuition Payment Plan Terms and Conditions outlined on the back panel.

__________________________________________ ___________________________________
Signature of participant Date


$75 Annual or $50 Semester application fee + $____________ =     $____________
  Payments   Amount enclosed


Your fee and payments due must be enclosed and cannot be withdrawn through either Direct Debit or Electronic Payment options.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 Heartland ECSI, PO Box 718, Wexford, PA 15090.)

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Yes, I want my monthly payments automatically withdrawn from my checking account.

I have enclosed a separate canceled or voided check for the checking account from which the payments will be withdrawn (this option is not available for savings or brokerage accounts).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 Tuition Payment Plan payment. Please note: Notification of the date of the first direct debit will be made in the Tuition 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 payments must be enclosed and cannot be paid through electronic billing.

__________________________________________ ___________________________________
Signature of Electronic Payment participant Date