East Tennessee State University
James H. Quillen College of Medicine
Resident Emergency Loan Fund Application & Promissory Note
To be completed by the resident:
Section I.
Name (Last) (First) (Middle/Maiden)
E Number Birth Date Classification (PGY 1, 2, 3, 4 or 5)
Home Address
Home Phone
Amount Requested
Driver’s License No./State Do you have an outstanding Resident loan?
Have you ever defaulted, bankrupted or become delinquent on a loan? _______________
Reason for requesting loan: ________________________________________________
Section II
I understand this is a promissory note. I promise to pay the University the sum of the
requested loan amount, or such loan amounts advanced to me plus interest and any costs
for the collection of this loan, according to the terms stated herein, and to which I am
entitled to an exact copy. I must notify the Lender if I change my name, address, or if I
withdraw from the residency program.
Resident’s Signature Date
There is no processing fee. The loan shall bear interest at the rate of nine (9%)
percent APR at the time the borrower ceases to be a resident and during repayment.
Resident loans do not bear interest during repayment unless the resident borrower
becomes delinquent.
The terms and conditions of repayment shall be set forth in a separate repayment
schedule which will be established at the time the loan is made, and under the conditions
of the Resident Emergency Loan Program. There are no provisions for extension of
repayment. Resident loans will become due as stated in the application and as printed on
the information sheet governing the loan program.
A delinquent borrower may be accessed a late charge of five (5%) percent of the
installment payment or $6.00, whichever is greater, on payments made later than 10 days
after the established due date.
Delinquent loans will be reported to credit bureaus. Collection of delinquent
loans will be pursued aggressively. *Paragraph see attached.
The unpaid balance on any loan shall be cancelled due to the death or total
disability of the borrower, regardless of whether or not the loan was endorsed.
I have read the RIGHTS and RESPONSIBILITES regarding this loan, together
with the provisions of the loan programs. I have been furnished with a repayment
schedule, informed about the costs of the loan, delinquency. I, at my option, may prepay
all or any part of the loan, without penalty, at any time.
Resident’s Signature Date
Department Chair Signature Date
I, the undersigned borrower identified in Part I (application) promise to pay to
East Tennessee State University, Johnson City, TN (lender) or the subsequent holder of
this Note, the amount requested; principal sum of $_________________
(written out) to the extent it is advanced to me and to pay interest or other charges on the
principal sum as set out herein. My signature certifies that I, have read, understand, and
agree to these conditions.
Resident’s Signature Date
MAXIMUM AMOUNT OF LOAN: Up to $1000 (extenuating circumstances
may warrant a larger loan).
REPAYMENT DATE: Loan matures one moth following
disbursement of check; repayment begins on
first day of month of maturity.
REPAYMENT SCHEDULE: Six (6) months for loans up to $500 or
twelve (12) months for loans greater that
MONTHLY PAYMENT: The amount of loan divided by six (6) or
twelve (12) months.
INTEREST: Loan interest is free; however, interest of
9% will be collected from all delinquent
payments. A report of delinquent accounts
will be sent and reported to department
TERMINATION: Loan must be paid in full should a resident
terminate the program.
PAYMENTS REMITTED TO: East Tennessee State University
Financial Services
Resident Emergency Loan Fund
Box 70736
Johnson City, TN 37614
TRUTH IN LENDING: See application form.
Date: _____________________
Amount of Loan Requested: $____________________________________
Resident’s Full Name: ___________________________________________
Resident’s E Number:_________________________________
Department: ___________________________________________________
Resident’s Projected Date of Residency Program Completion:____________
Account Number of Loan Fund: __________________________________
Purpose of Loan: ______________________________________________
Check To Be Sent to One of the Following:
_________ Resident Home Address _______________________
_________ College of Medicine Department of ______________
_________ Other ______________________________________
Approved: ____________________________________________________
Chair of the Department
Associate Vice President
Department Contact Person: _______________________________________
First Payment of Loan Due By: __________________
Last Payment of Loan: _________________________
Monthly Payment Amount: $___________________
East Tennessee State University
Johnson City, Tennessee 37614
Student Promissory Note
For Receipt of Short-Term University Loan
Amount of Loan: $ __________ Loan Date: ___________ Due Date: __________
On or Before _____________I/We promise to pay to the order of East Tennessee State
University, Johnson City, TN $_______________dollars for value received, with interest
at ten (10) percent, from (date) _____________until payment of principal is paid or a
minimum processing charge $______________, whichever is greater, is paid. Said loan
shall be due on or before the above date, if the University in the name of the Maker
receives financial aid in excess of tuition and fees. The Maker further agrees that if any
debt of the Maker is due the University, any funds that are received by the University in
the name of the Maker shall be held by the Bursar and applied to the debt. Any excess
funds will be released to the maker after all University Debts are paid.
The Borrower promises to pay the University the sum of the amount advanced to
Borrower under the terms of this Promissory Note, plus processing fee. The Borrower
further promises to pay all reasonable collection costs, including attorney fees and other
charges, necessary for the collection of any amount not paid when due.
My signature (Maker’s signature) certifies that I have read, understand, and agree to the
terms and conditions of this Promissory Note.
Loan Amount: _______________________________________________
Student’s (Maker’s) Signature: ________________________________________
Print Student’s Name: _______________________________________________
Student’s Social Security Number: _____________________________________
Student’s Place of Employment: _______________________________________
Cosigner Data:
Cosigner’s (Endorser’s) Signature: _____________________________________
Print Cosigner’s Name: ______________________________________________
Cosigner’s Social Security Number: ____________________________________
Cosigner’s Address: _________________________________________________
Cosigner’s Home Telephone Number: __________________________________
Cosigner’s Work Telephone Number: ___________________________________
Cosigner’s Place of Employment: ______________________________________
Version 1/16/2019