Tpeg Short Term Loan Application And Promissory Note Page 3
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4HOUSTON COMMUNITY COLLEGE
TPEG SHORT TERM LOAN APPLICATION AND PROMISSORY NOTE
(For Tuition, Fees and/or Books Only)
INSTRUCTIONS: Print carefully so your application can be easily read. Answer all questions in ink. Incomplete applications will not be accepted.
Section A: Yourself
Your Name: Last
First
M.I.
_
Last 4-digits of SS#
Date of Birth:
Email address:
Driver’s License No/State:
Home Telephone (
)
Alternate Telephone (
)
Work (
)
Permanent Mailing Address:
City:
State:
Zip:
Current Employer:
Employers’ Address:
City:
State:
Zip:
Section B: Requested Assistance
Section C: Sources of Repayment
Tuition: $
Source of funds for repayment (circle two that apply)
Parent’s Income
Books: $
Unemployment Benefits
Veterans Benefits
Total:
$
You/Spouse’s or/parent Employment
Earnings
Section D: References
You must provide information for three different adults with different U. S. addresses and phone numbers. These must be individuals who will know
where to locate you, if necessary. They will not be used as character references to determine your ability to repay the loan. List next of kin first (e.g.
parent, guardian, spouse, or relatives), then employer, friends, etc. Do Not Leave Any Item Blank.
Reference 1
Reference 2
Reference 3
Name: _________________________________
__________________________________
_____________________________________
Street: __________________________________
___________________________________
_____________________________________
City/St/Zip: ______________________________
___________________________________
_____________________________________
Telephone: _______________________________
___________________________________
_____________________________________
Relationship: ______________________________
___________________________________
_____________________________________
Employer: ________________________________
___________________________________
_____________________________________
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