Date of Graduation, Withdrawal or below ½ time from Jacksonville State University_____________________
Name_________________________________________ Student # ________________________________
Date of Birth__________________Drivers License Number____________________State___________________
Marital Status: Married __ Single __ Divorced __ If married, Spouses Name__________________________
Email address ______________________________________________________ Telephone ______________
Expected Employer (if known) ___________________________ Work number__________________________
(If PO Box is listed below, please list street address also)
Statement Mailing Address: Student Permanent Address:
PO Box/Street____________________________________ ________________________________________________
Street___________________________________________ ________________________________________________
City/Stat/.Zip____________________________________ ________________________________________________
Phone number____________________________________ ________________________________________________
E-Mail Address____________________________________ ________________________________________________
Name of Employer_________________________________ Work Telephone__________________________________
Address__________________________________________ Position_________________________________________
City_________________County___________State___________Zip___________ Date employment begins_____________
If your address changes after leaving Jacksonville State University, you MUST provide written request to either the Bursar’s
or the Registrar’s Office in order for updates to be made on the Student Loan System.
Rights and Responsibilities Summary Checklist
I understand that I have a right to the following: (Check off each box as you read.)
A disclosure statement, received before I begin to repay my loan, which includes information about interest rates, fees, the
balance I owe, and the number of payments, when the first payment is due and how much the first payment is.
A grace period and an explanation of what this means.
Logan Walker Loans qualify for deferment if the student is enrolled at least half time at JSU and request the deferment
Prepayment of my loan in whole without an early-repayment penalty.
Documentation that my loan is paid in full.
I understand that I am responsible for: (Check off each box as you read.)
Repaying my loan even if I do not complete my academic program, I am dissatisfied with the education I received, or I am
unable to find employment after I graduate.
Keeping my address and name current with Jacksonville State University if I move/change my address or change my name.
Making monthly payments on my loan after my grace period ends.
NOTE: Each month a payment must be posted by the due date to keep the late charge from accruing on the account.
Payments in excess of the minimum amount due can be made but will post to the principle loan amount in the month they
are received.
Notifying the Bursar’s Office (located in Room 245 Bibb Graves or (256) 782-5262) of my enrollment status.
I understand the seriousness and importance of repaying my student loan(s). Failure to repay my loan is likely to result in
the following consequences:
My Loan(s) may be referred to a collection agency.
The entire unpaid amount of my loan, including interest, late charges, court costs, and collection or
attorney fees may become due and payable immediately, and I may lose any rights to a deferment.
I may have a negative rating for seven years or more appearing on my credit report.
I have received exit-counseling materials. I have read and I understand my rights and responsibilities as a borrower. I understand
that I have a loan from Jacksonville State University that must be repaid and is not eligible for consolidation.
___________________________________________ __________________________
Student’s Name (Please Print) Student ID Number
___________________________________________ __________________________
Student’s Signature Date
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