Student Application Form

Emergency Loan Fund

Instructions: Please complete the Application Form and the Sign-off Form (see next page). Both forms must be fully completed before they are submitted to CCRI's Office of Institutional Advancement. Incomplete forms cannot be considered for funding. Please print clearly or type.

Name:_____________________________________ Student I.D. # #__________________________

Address:___________________________________ City________________ State______ Zip_______

Telephone:__________________________________ e-mail __________________________________

1. List current or most recent Nursing, Allied, Dental or Rehabilitative Health course registrations.

2. Describe the extenuating circumstances, which have developed causing you to need a *loan at this point in time.

Have you ever received a loan from this fund? Yes___ No___

If yes, how much was the loan? ________

4. Expected date of graduation? _____________

5. I am requesting a loan of $________(cannot exceed $200)

6. I agree to repay this loan to the CCRI Foundation* on or before

__________________.
(Date of repayment)

I grant my permission to the Scholarship Review Committee to review my academic standing with CCRI's Office of Admissions and Records and to review my financial need with CCRI's Financial Aid Office.

______________________________________________
Signature/Date

*Loan repayments should be made payable to the CCRI Foundation and sent to CCRI's Office of Institutional Advancement, 1762 Louisquisset Pike, Lincoln, RI 02865-4585.

This page developed and maintained by the CCRI Foundation at CCRI. Send comments and suggestions to foundation@ccri.edu.  ©2009, Community College of Rhode Island.

This page last modified on: July 21, 2009