TUITION REIMBURSEMENT DEFERRED PAYMENT PLAN

Long Island University - C.W. Post Campus

Promissory Note

Tuition Reimbursement Deferred Payment

I am employed by_______________________________________________________

where I am eligible for coverage by a tuition reimbursement plan. Attached is a letter from my employer verifying my employment and eligibility in my employer's tuition reimbursement program. Therefore, I request an extension for my___________________semester /session tuition until grades are issued. In return for permission to continue in attendance, I promise to pay my tuition account in full within three weeks after the end of the semester, whether or not the total amount of my tuition obligation has been issued to me by my employer. If my employer requires a transcript, Long Island University will release a transcript to them, pending my written request for one and payment of the $5.00 fee. I further understand that I will not receive my student transcript until the amount of my tuition is paid-in-full.

I understand that I may not be granted any future Tuition Reimbursement Deferred Payment Plans until this balance has been paid. I understand and agree to the terms and conditions of the Tuition Reimbursement Deferred Payment Plan of Long Island University and acknowledge that this agreement is a binding obligation even though I may be under 21 years of age. I further understand that if any of my reimbursement benefits are reduced or denied, I am responsible for all indebtedness involved. I agree to pay all collection costs, attorney's fees and disbursements should the University turn this account over to an outside collection agency. I also agree to pay a $25.00 late payment fee if my payment is delinquent.

Student's Name:_______________________________________	Student ID Number________________________
Student's Signature_____________________________________	Date_____________________________________

Please return this form and the letter from your employer to:
Long Island University - C.W. Post Campus
Bursar's Office, Kumble Hall
720 Northern Blvd., Brookville, NY 11548

FOR BURSAR'S USE ONLY:

SEMESTER/SESSION_______________ TOTAL CREDITS REGISTERED FOR_________.

TOTAL TUITION	____________________________
FEES	____________________________
TOTAL CHARGES	____________________________
TOTAL TO BE PAID BY EMPLOYER	____________________________
BALANCE	____________________________
AMOUNT PAID	____________________________

APPROVED BY______________________________DATE________________________________