Forgivable Loan Application - Non-Tcl Participant (Archdiocese Of Dubuque)

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MA in Education at Clarke University
Archdiocese of Dubuque - Forgivable Loan Application – Non-TCL Participant
Name: _______________________________________________ SS#: _______________________________
Address: _____________________________________________ Home Phone: ________________________
City: ______________________________ State: ___________ Zip: ________________________________
Email Address: _____________________________________________
Employing School and Location: ______________________________________________________________
Current Position: ______________________________________ Number of years in current position: ______
Number of years teaching in Archdiocese of Dubuque schools: ______________________________________
Directions: Forgivable loans are only available for courses taught by Clarke University that are not taught in the
TCL program. Forgivable loans will only be awarded to a maximum of 18 hours per individual. List the courses
taught by Clarke, which you will be taking and wish to apply for a forgivable loan during the 2016-2017
academic year. Courses not successfully completed will result in forfeiture of the loan and immediate payback
to the Archdiocese for money received. Return this form to Clarke University.
Course #1
Course Title: __________________________________________ Course Number: ______________________
1st Semester 2016
2nd Semester 2017
Summer 2017
Course #2
Course Title: __________________________________________ Course Number: ______________________
1st Semester 2016
2nd Semester 2017
Summer 2017
Course #3
Course Title: __________________________________________ Course Number: ______________________
1st Semester 2016
2nd Semester 2017
Summer 2017
Course #4
Course Title: __________________________________________ Course Number: ______________________
1st Semester 2016
2nd Semester 2017
Summer 2017
Forgivable Loan Contract
If I receive an Archdiocesan forgivable loan, I agree to serve the Archdiocese of Dubuque for a period of three years
immediately following receipt of the forgivable loan for the courses listed above. If for any reason I am unable to serve
for the agreed period, I will repay the Archdiocese of Dubuque on a prorated basis as follows, except in the case of death
or disability: the entire amount if no service is provided; 2/3 if one year is completed; 1/3 if two years are completed. I
will make payment in installments as mutually agreed upon with the Office of Faith Formation and Education.
Signature: ______________________________________________
Date: _________________________
Please do not write in this box.
Application Received:
Application Reviewed:
Decision by Committee:
Yes
No
Amount: $
Date contract signed:
Updated August 1, 2016

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