Payment Plan Application

Student's First Name

Student's Last Name

Phone

Social Security Number

Please Select Your Payment Option below:

PAYMENT OPTIONS PAYMENT OPTIONS 1. Pay Cash (Cash, Check, Florida Pre-Pay, GI Bill, Vocational Rehab) 2. Short-Term Payments (Monthly Payments while in School- Interest Free) 3. Long-Term Payments (Monthly Payments 12 – 72 Months 3%-9% Interest. Payments cover Tuition Only. There is a $25 application fee)

Which Credit Card will you be using? Which Credit Card will you be using? Master Card Visa

Credit Card Number

Name on Card

Expiration Date

Credit Card Security Code

Credit Report Credit Report I authorize Cosmix to run a Credit Report

Total Monthly Income

Employer's Name

Employer's Address

Employer's Apt/Suite

Employer's City

Employer's State/Province

Employer's Zip/Postal Code

Employer's Phone Number

Length of Employment

Student's Signature

Are you submitting with a Cosigner? Are you submitting with a Cosigner? Yes No

Cosigner's First Name

Cosigner's Last Name

Cosigner's Address

Cosigner's Apt/Suite

Cosigner's City

Cosigner's State

Cosigner's Zip/Postal Code

Cosigner's Email

Cosigner's Phone

Cosigner's Date of Birth

Cosigner's Social Security Number

Cosigner's Total Monthly Income

Credit Report Credit Report I authorize Cosmix to run a Credit Report

Cosigner's Signature

There is a $25 fee that must accompany this application There is a $25 fee that must accompany this application Visa Mastercard

Credit Card Number

Name on Card

Expiration Date

Security Code (CVV)

Billing Zip Code

Credit Card Holders Signature