Student Name
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First Name
Last Name
TSU ID (T-No)
*
Email
*
Home Phone
Cell Phone
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Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
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Virgin Islands, U.S.
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Country
Outstanding Account Balance($)
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Cumulative GPA
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Anticipated Graduation Date
*
Promissory notes are approved based on your financial aid awards. Please verify that you will be receiving enough financial aid to cover your past due balance and any charges for the upcoming term. Please upload supporting financial aid documents.
Accepted file types: pdf, doc, docx, ppt, pptx, xsl, xslx, jpg, png.
Consent Agreement
Promissory Note Terms & Conditions:
I promise to fully repay this promissory note as shown, on or before the 1st class day of the upcoming term. I understand this promissory note represents an obligation to TSU. I understand that
A STUDENT WHO FAILS TO MAKE FULL PAYMENT OF TUITION AND FEES, INCLUDING ANY INCIDENTAL FEES, BY THE DUE DATE MAY BE PROHIBITED FROM REGISTERING FOR CLASSES AND RECEIVING TRANSCRIPTS UNTIL FULL PAYMENT IS MADE. A STUDENT WHO FAILS TO MAKE FULL PAYMENT PRIOR TO THE END OF THE SEMESTER OR TERM MAY BE DENIED CREDIT FOR WORK DONE THAT SEMESTER OR TERM
. I understand that a Texas state hold can be placed on my account and that the past due promissory note can be sent to a collection agency. I agree to pay any and all collection costs associated with this promissory note. I hereby authorize TSU to initiate a transfer from my student account and apply against the balance remaining on my promissory note if allowable by DOE. If I withdraw from TSU for any reason, the amount of the promissory note is due immediately. I also understand that my signature represents that I have read and am in full agreement with the requirements for this promissory note. Payments on the promissory note are to be made at the Customer Service window in the Bell Building at 3100 Cleburne Avenue, Houston, Texas 77004 ∙ (713) 313-7052. The terms of approved promissory notes will be available and will not change for 30 days after approval except as a result of adjustments permitted by law.
I certify that all information provided is true, accurate, and complete.
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Yes
Signature
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Date
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Phone
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