CONSORTIUM AGREEMENT FOR FINANCIAL AID PURPOSES
BETWEEN
The Home Institution The Host Institution
J. Sargeant Reynolds Community College (JSRCC) Name: ___________________________________________
Office of Financial Aid Street Address: ___________________________________
P.O. Box 85622 City, State, Zip: ___________________________________
Richmond, VA 23285-5622
Fax Number : (804) 371-3739 Fax Number (____) ___________________________
Section I: To be completed by the student
Name :_____________________________________________________ Emplid Number:________________________________________
Home Address: _____________________________________________ Contact Number: (________) _____________________________
City:______________________ State:_______________ Zip:________ JSRCC email address: ___________________________________
Consortium Term: _________ Fall __________Spring _________Summer
Statement of Authorization:
I agree to: I understand that:
• Submit this form to JSRCC and to my Host Institution for
completion.
• Inform JSRCC immediately if I choose not to enroll or
otherwise cancel my participation in the program.
• Allow JSRCC and my Host Institution to share information
relating to my enrollment and financial aid eligibility.
• Maintain satisfactory academic progress.
• Request the Host Institution to mail an official transcript of
all class grades to the JSRCC Central Admissions and Record
Office
• JSRCC will not provide early release of financial aid or send
payments to my Host Institution.
• I am responsible for any payment due to my Host Institution
prior to their payment deadlines as my funds at my JSRCC
cannot, under any circumstances, be released until after the
last day to drop a class with a refund at JSRCC.
• This agreement does not guarantee an increase in the amount
of financial aid I will be eligible to receive.
Student Signature:________________________________________ Date:__________________________________
Section II: To be completed by Host Institution
The above student may attend the Host Institution as a visiting student and has registered for the following course(s):
Course Title Credit Hours Course Title Credit Hours
1. 4.
2. 5.
3. 6.
Please indicate the student’s estimated tuition/fees and books for all the courses listed above:
Tuition/Fees: __________________
Books: _______________________ Is the Host Institution eligible to award Federal Title IV financial aid?
Total: ________________________ Yes No
Statement of Certification:
The Host Institution agree to:
• Not process or award any Federal Title IV financial aid for this student
• Share information about this student’s enrollment including notifying JSRCC if the student withdraws from the program or decreases enrollment
before its conclusion
Host Institution Financial Aid Office Staff Signature:______________________________________________________ Date:___________________
Print Name:____________________________ Office Phone Number:_____________________ Office Fax Number: _____________________
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