Before You Leave: Exit Counseling for Student Borrowers

Student ID:*
Ex. P10000000; Must include the letter "P"
Full Name*
First Last
Date*
MM slash DD slash YYYY
Current Address*
Street Address City State ZIP Code
Permanent Address After Leaving School*
Street Address City State ZIP Code
Phone*
Email*
Do you plan to continue your education?*
- Yes
- No
If yes, where and when?*
References
Reference 1 Name*
First Last
Relationship*
Address*
Street Address City State ZIP Code
Phone*
Email*
Employer
Reference 2 Name*
First Last
Relationship*
Address*
Street Address City State ZIP Code
Phone*
Email*
Employer
Reference 3 Name*
First Last
Relationship*
Address*
Street Address City State ZIP Code
Phone*
Email*
Employer
Current Employer
Company
Phone
Address
Street Address City State ZIP Code
Position
Signature of Borrower*
Enter Your Last Name and Last Two Digits of Your Student ID Number
Date*
MM slash DD slash YYYY

References