Payment plan application

Coaching Program Financing Application

Apply for a payment plan over time. It takes a few minutes.

Fill in every field you can. Your answers go straight to the program administrator — nothing is public. Please do not enter a Social Security number, a full card number, or any bank login.

Applicant

Full legal name*

Preferred name

Date of birth

Email*

Mobile phone*

Best time to call

Street address

City

State

ZIP

How did you hear about the program?

Program and amount requested

Program name or cohort

Start date or cohort month

Total program cost

Deposit you can pay now

Amount to finance

First payment date

Preferred payment schedule

Term requested

If other, number of months

Preferred monthly payment

Preferred payment day of month

How do you prefer to pay?

If other payment method, describe

Employment and income

Employment status

Employer or business name

Job title

Years at job

Monthly take-home income

Other monthly income

Source of other income

Monthly obligations

Monthly housing, rent or mortgage

Other monthly debt payments

Dependents

Anything that could affect on-time payments

Why this program

What result are you enrolling for?

Why do you need the balance financed over time?

Emergency contact

Name

Relationship

Phone

Authorization

I confirm the information on this form is true to the best of my knowledge. I am applying for a payment plan for the coaching program named above. I understand this form is an application only, that approval is not guaranteed, and that a separate payment agreement will be provided if a plan is offered. I authorize the program administrator to contact me about this application.

I agree to the statement above.*

Signature (type full name)*

Date

Printed name

This is an application only. Approval is not guaranteed. A separate payment agreement is provided if a plan is offered. Do not enter a Social Security number, a full card number, or any bank login.