MESALANDS COMMUNITY COLLEGE
2019-2020 DEFERRED PAYMENT PLAN APPLICATION
Complete and return this application ONLY if you choose to pay in monthly installments. If you will pay in full each this semester, you
DO NOT need to return this application. Payment plans do not carry over to the next semester, you must reapply.
Payment plans will only include tuition, fees, and books. Supplies will only be included in a payment plan that has been approved by the
Business Manager or the Director of Business & Auxiliary Services.
(Payment of the application fee must accompany this application)
Payment Plan Payment Period Payment Due Payment Amt.
App. Fee
3 Monthly Payments
August 2019 - October 2019
August 15, 2019
September 13, 2019
STUDENT INFORMATION
Student Name Student ID#
(First) (MI) (Last)
Birthdate Driver’s License# State
Local Address City State Zip
Off-Campus Address City State Zip
Email address
PARENT/ SPOUSE/GUARDIAN CONTACT INFORMATION
Name Address City, State Zip Home Telephone Cell Telephone
Mother
Father
Spouse
Legal Guardian
Default: If I fail to make any payment required by this plan when due, the entire balance shall become due and payable without notice
and on demand. You agree to pay on demand all costs and expenses of collection including reasonable collection agency and attorney
fees incurred or paid by the College in attempting to enforce payment of this Plan.
A late fee of $10.00 will be required for each defaulted payment. This fee will be applied to your account the following day the payment
is due.
In the event I default on one of the required payments, I will not be allowed at ANY time in the future to set up a Deferred Payment
Plan with Mesalands Community College to pay for tuition, fees, books, or supplies.
In the event I default, the College has the right to deny my attendance to class, to register/enroll at the College, and/or withhold my
transcripts until the default is cured.
By signing this form I agree that in the event that my payments are delinquent that my parent, guardian or spouse may be contacted
for purposes of locating me. I hereby certify that the above information is true and correct to the best of my knowledge.
Signature
Date
If you have any questions, please contact the Business Office at (575) 461-4413 ext. 110
ai 0814
mr JICS 1014
Telephone ______________________
October 11, 2019
