Deferred Payment Agreement Form – White Mountain Community College

White Mountain Community College > Current Students > Student Forms > Deferred Payment Agreement Form

Year
- Fall
- Spring
- Summer
AMOUNT DEFERRED $
Deferred Plan
- Financial Aid
- Third Party
- NBS Payment Plan
Student Name*
Student ID #
Address
Street or PO Box City State ZIP Code
Primary Phone
Cell Phone
Email
Date of Birth
Date Format: MM slash DD slash YYYY
Driver’s License #
State
Place of Employment
Work Phone
Address
Street Address City State ZIP Code
Parent’s Name
Telephone
Parent’s Address
Street Address City State ZIP Code
Please list a person who we may contact if we are unable to reach you at the numbers/address(es) you have provided on this form.
Reference Name
Telephone
Address
Street Address City State ZIP Code
IN SIGNING THIS AGREEMENT, I AM INDICATING MY UNDERSTANDING AND AGREEMENT THAT:
1. Payment must be made in accordance with the Deferred Payment Agreement Plan outlined above.
2. If I do not make payment as scheduled above, I will be allowed to finish the course, but I will be unable to receive an official transcript, certificate, professional certificate, or degree.
3. Furthermore, I will not be able to register for future terms at the college and will be restricted from registering at other CCSNH colleges.
4. If payment is made, I will be allowed to register for future classes, however, full payment of all tuition and fees for any new classes may be required before the semester/term begins.
5. If I fail to make a payment as scheduled, I will receive a letter from the Business Office informing me that payment must be made within 14 calendar days. If payment is not made within that timeframe, my account will be referred to Educational Computer Systems Inc.(ECSI). If my account is not cleared up at that point, my account will be turned over to the credit bureau and an outside collection agency.
6. WMCC can contact me using the phone numbers listed above.
I agree that by registering for courses within the Community College System of New Hampshire (CCSNH), I am financially obligated for ALL costs related to the registered course(s). Upon a drop or withdrawal, I agree that I will be responsible for all charges as noted in the student catalog and handbook. I further understand that if I do not make payment in full, my account may be reported to the credit bureau and/or turned over to an outside collection agency. I also agree to pay for the fees of any collection agency, which may be based on a percentage of the debt up to a maximum of 35%, and all additional costs and expenses, including any protested check fees, court filing costs, and reasonable attorney’s fees, which will add significant costs to my account balance.
Signature
Date
Date Format: MM slash DD slash YYYY

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Students enrolled fall 2019