Statement Of Financial Responsibility Tuition Deferment For Company Reimbursement Form - Rollins College
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ROLLINS COLLEGE
■ HAMILTON HOLT SCHOOL
STATEMENT OF FINANCIAL RESPONSIBILITY
TUITION DEFERMENT FOR COMPANY REIMBURSEMENT
Student Name:_________________________________________ R#:_________________________
Home Address:_______________________________________________________________________
City, State, Zip:_______________________________________________________________________
Phone:__________________________________ E-mail:_____________________________________
COMPANY INFORMATION
Employer Name:______________________________________________________________________
Employer Address: ___________________________________________________________________
City, State, Zip:_______________________________________________________________________
This is to certify that the above-referenced student has applied for and is eligible for tuition reimbursement upon
successful completion of registered classes in accordance with company policy. This certification in no way obligates
the Company to Rollins College for payment of charges incurred by the student.
AUTHORIZED COMPANY REPRESENTATIVE
Name: _____________________________________ Title: ___________________________________
(Please Print)
(Please Print)
Signature
Date
Phone
REGISTRATION INFORMATION
Please note that a new deferment form is required for each term.
Term:
Year: ______________
______Fall
______Spring
______Summer
Course No.
Title
Credits
Tuition
________
__________________________________________________ _________
_________
________
__________________________________________________ _________
_________
________
__________________________________________________ _________
_________
________
__________________________________________________ _________
_________
Total Due: $ ____________________
CONTRACT
Payment of the total due will be submitted to Rollins College within 45 days after the end of the term. I affirm that I will be
responsible for the payment of the above-noted charges, including all attorneys' fees and other costs and charges necessary for the
collection of any amount not paid when due, and that I will comply with the regulations regarding fees, expenses, and refunds
outlined in the current Rollins College Catalog and course schedule. I understand that there will be no refunds issued to me as long
as this deferment remains unpaid. Furthermore, I understand that transcripts and diplomas will not be released and future
registration will be disallowed with a past due balance owed to Rollins. I understand that in the event of default the debt will be the
sole responsibility of the student until it is paid in full, and that students who fail to pay the deferred balance within the 45-day
limit will be prohibited from receiving future deferments (late payment fees will apply).
I hereby certify that I have read and agree to the terms and conditions stated above.
Student Signature: _____________________________________
Date: _______________________
Submit to the Hamilton Holt School Office on or before the published term payment deadline. Confirmation of acceptance will be
sent to the student’s Rollins e-mail account.
Rollins College • Hamilton Holt School • 203 East Lyman Avenue • Winter Park, FL 32789
Phone: 407-646-2232 • Fax: 407-646-1551
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