STUDENT’S NAME _______________________________________ ANDREWS UNIVERSITY ID NUMBER ____________
LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER _____________ TELEPHONE/MOBILE ________________________
STUDENT’S EMAIL ADDRESS _______________________________ DRIVER’S LIC. #/STATE _____/_________________
MAILING ADDRESS ____________________________________________________________________________________
Is the above address: Temporary Permanent? If temporary, how long will this address be good? _____________________
Please call me to discuss my account. The best time to call would be ______________________________________
I plan to return next semester. Please indicate your plans to clear your balance before registration by filling out page two.
I am currently unemployed. My plans for employment are as follows: _________________________________________
_________________________________________
I am employed.
Employer’s name______________________________________________ Phone _____________________________
A
ddress _____________________________________________________ Can we contact you at work? Yes No
DO NOT SKIP. This information is required. (i.e. parent, spouse, friend, pastor, etc.)
Name
Name
Street
Street
City
City
State-Zip
State-Zip
Phone
Phone
Relationship
Relationship
Name
Name
Street
Street
City
City
State-Zip
State-Zip
Phone
Phone
Relationship
Relationship
Don't forget to complete page two.
.
COLLECTIONS EXIT INFORMATION SHEET
STUDENT INFORMATION
REFERENCE INFORMATION
6/18/2020
I can start my payments immediately. Enclosed is my first payment.
I have made arrangements earlier and would like to continue. This arrangement is:
I have not yet made arrangements and would like to propose the following:
o US check or money order (mailed to the SFS address below)
o e-Check
(US checking or savings account, free on TouchNet® - www.andrews.edu/sfs)
o Credit card (also through TouchNet®, 2.75% convenience fee applies)
o Wire
(through Flywire - http://www.flywire.com/)
o Cash or check at SFS Cashier window. We are currently unable to accept credit card payments over the phone or
in person.
This is only a proposal for payment and will need to be approved. Once a payment schedule is approved, a payment agreement form will be sent to you. Only when
the payment agreement form is signed and received by Student Financial Services, does your payment schedule go into effect. All payment schedule information is
shared with the Credit Bureau and payment information is updated monthly. Without a payment schedule, the full balance on your account is due and payable
immediately. If it becomes necessary to send your account to a third party collector, you will be responsible for collection costs which is 2-50% of your student account
balance. If you have any questions, please contact the Collections office at 269-471-3593 or at collections@andrews.edu
.
By my signature, I verify that all the information supplied on this form is correct.
SIGNATURE_______________________________________________________________ DATE ___________________
Mail to: Andrews University Fax to: 269.471.3228
4150 Administration Drive Phone: 269.471.3593
Berrien Springs, MI 49104-0750 Web: www.andrews.edu/sfs
Attn: Student Financial Services-Collections Email: collections@andrews.edu
PROPOSED PAYMENT PLAN
PAYMENT METHOD
COMMENTS