Payment Form - The Center For Scholarship Administration printable pdf download

CENTER FOR SCHOLARSHIP ADMINISTRATION

4320 Wade Hampton Boulevard, Suite G ♦ Taylors, SC 29687

Phone: 1-866-608-0001 ♦ Fax: 1-864-268-7160

PAYMENT FORM

As the recipient of a scholarship administered by the Center for Scholarship Administration I am requesting that the

college provide verification of my enrollment for the current term.

STUDENT MUST COMPLETE AND SIGN PART I:

PART I – STUDENT

(print legibly)

Student’s Name____________________________________________________________________________

Student ID# (if assigned by college) ____________________ Student Email:_____________________________

Name of Scholarship_____________________________________________________________________________

Anticipated year of graduation _________Current Classification (FR, SO, JR, SR, GR)________________________

Student’s Signature___________________________________

Date ____/_____/______

NOTE: You must submit a completed Payment Form no later MARCH 15, 2017. It is the

student’s responsibility to ensure the college completes and submits the form prior to the

deadline dates. Forms received after the deadline date will not be honored. No payments will be

made after MARCH 15, 2017.

REGISTRAR MUST COMPLETE AND SIGN PART II:

PART II – REGISTRAR

(print legibly) Must Be completed by your school.

CHECK EITHER A OR B; AND C:

NOTE: Please complete the portion below and mail OR fax to the information above.

A: I certify that the above named student is pre-registered for the term listed below.

___Fall ___ Winter ___ Spring ___ Summer

Year ___________

(i.e.,if the request is for the 2016-2017 academic year, please check the term and write in 16-17 beside year)

B: I certify that the above named student is enrolled for the term listed below.

___Fall ___ Winter ___ Spring ___ Summer

Year ___________

(i.e., if the request is for 2016-2017 academic year, please check the term and write in 16-17 beside year)

C: I certify that this student is either preregistered or enrolled as a:

______________Part time or _______________Full Time Student

Please issue a check payable to:

Name of College ____________________________________________________________________

Specify Office for mailing payment______________________________________________________

Mailing Address_____________________________________________________________________

City, State, Zip______________________________________________________________________

Name of Person verifying information _____________________ Date of verification__________________

Signature of Person verifying information ____________________Email Address____________________

Phone Number (______) _________________ Fax Number (_____) __________________________

Date Payment Due______/_______/______

Payment Form - The Center For Scholarship Administration