TCU Persistence Application for Internet Assistance

TCU Persistence Application for Internet Assistance
Name:

First Name Last Name
SID#:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Message Phone Number
Please enter a valid phone number.
Email
example@example.com
I am applying as:

Student (please continue to answer the following 5 questions.) Staff (if you are staff, please skip the next 5 questions and continue to description of need.)
Declared Major:
Cumulative GPA:
# Attempted of Credits:
# Earned Credits:
Gender:
Class:
5. Current educational Status:
Description of current need (choose one):

Transportation (Car repair, etc.) Rent/Housing Utilities Insurance Food and Gas Other
Describe the in detail description of current need:
Currently, we are only able to assist you with your internet costs at this time, we will
need you to provide a copy/copies of a current bill, or other charges relating to the
internet costs*.
Upload current internet billing statement:

Cancel of
Signature *

Clear
Date *

Month Day Year
Date
*We are not responsible for payments that are late for reasons beyond our control, including payments that are scheduled to be paid after the due date, lost in the mail or misdirected due to incorrect address or remittance information revised 09-21-2020
Should be Empty: