AmeriCore Finance Student Extended Payment Plan Application

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Email Address* This field is required.
example@example.com
4
DL Number* This field is required.
5
Social Security Number* This field is required.
6
I authorize AmeriCore Lending to obtain a soft credit inquiry for enrollment and financing review. I understand this inquiry will not affect my credit score.* This field is required.
7
Phone Number* This field is required.
Please enter a valid phone number.
8
Current Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Net Monthly Income (What You Take Home)* This field is required.
10
What time of day are you available for CMTC to contact you?* This field is required.
Morning
Midday
Evening
Any
11
There is a $300 Enrollment Fee that is due to get this Extended Payment Plan Established.* This field is required.Your enrollment fee is not due until your extended payment plan is approved. Enrollment fees cover your registration fee, lab fee, and administrative fees to establish your school account.
I Understand
12
When do you plan to start classes at CMTC?* This field is required.
Please Select
As soon as possible
within the next 3 months
within the next 6 months
13
Program of Study* This field is required.
Please Select
Please Select
Multi Medical Assistant
Medical Assistant
Phlebotomy Technician
EKG Technician
Billing and Coding Specialist
Medical Administrative Assistant
Surgical Technician
Dental Assistant
14
Choose your Preferred Payment Frequency
Please Select
Please Select
Weekly
Biweekly
Monthly
15
Preferred Plan
Please Select
16
Choose your Preferred Payment Terms
Please Select
Phlebotomy Weekly -
17
Employer Name
18
Employer Phone Number
19
Job Title
20
Length of Employment (Start Date)
21
Pay Frequency* This field is required.
Weekly
Bi Weekly
Monthly
Not Currently Working
22
Gross Monthly Income* This field is required.
23
Upload Your Last 30 Days worth of Check Stubs
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload a File
Cancelof
24
Upload 2 months of Bank Statements
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Loans won’t be considered without these documents.
Cancelof
25
Name* This field is required.
First Name
Last Name
26
Email* This field is required.
example@example.com
27
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
28
Phone Number* This field is required.
Please enter a valid phone number.
29
Relationship* This field is required.
30
* This field is required.
I understand late payments and NSF fees will apply.
I understand withdrawal or dropping the program does NOT cancel my financial obligation unless classes where not atteneded.
I agree that missed payments WILL result in my balance being sent to collections.
I certify that all information provided is true and accurate.
31
Name
First Name
Last Name
32
Date
Date
Month
Day
Year
33
Phlebotomy Technician - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
2 Months
3 Months
4 Months
34
Phlebotomy Technician - 2 Months - Payment Options
Please Select
Please Select
Weekly — $141.92
Biweekly — $283.85
Monthly — $615.00
35
Phlebotomy Technician - 3 Months - Payment Options
Please Select
Please Select
Weekly — $106.15
Biweekly — $212.31
Monthly — $460.00
36
Phlebotomy Technician - 4 Months - Payment Options
Please Select
Please Select
Weekly — $88.27
Biweekly — $176.54
Monthly — $382.50
37
Administrative Assistant - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
2 Months
3 Months
4 Months
38
Administrative Assistant - 2 Months - Payment Options
Please Select
Please Select
Weekly — $114.81
Biweekly — $229.62
Monthly — $497.50
39
Administrative Assistant - 3 Months - Payment Options
Please Select
Please Select
Weekly — $88.08
Biweekly — $176.15
Monthly — $381.67
40
Administrative Assistant - 4 Months - Payment Options
Please Select
Please Select
Weekly — $74.71
Biweekly — $149.42
Monthly — $323.75
41
Pharmacy Technician - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
2 Months
3 Months
4 Months
42
Pharmacy Technician - 2 Months - Payment Options
Please Select
Please Select
Weekly — $114.81
Biweekly — $229.62
Monthly — $497.50
43
Pharmacy Technician - 3 Months - Payment Options
Please Select
Please Select
Weekly — $88.08
Biweekly — $176.15
Monthly — $381.67
44
Pharmacy Technician - 4 Months - Payment Options
Please Select
Please Select
Weekly — $74.71
Biweekly — $149.42
Monthly — $323.75
45
Billing and Coding - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
2 Months
3 Months
4 Months
46
Billing and Coding - 2 Months - Payment Options
Please Select
Please Select
Weekly — $132.69
Biweekly — $265.38
Monthly — $575.00
47
Billing and Coding - 3 Months - Payment Options
Please Select
Please Select
Weekly — $100.00
Biweekly — $200.00
Monthly — $433.33
48
Billing and Coding - 4 Months - Payment Options
Please Select
Please Select
Weekly — $83.65
Biweekly — $167.31
Monthly — $362.50
49
Medical Assistant - Extended Plan DurationHow long you would like to extend your payment out.
Please Select
Please Select
3 Months
4 Months
5 Months
50
Medical Assistant - 3 Months - Payment Options
Please Select
Please Select
Weekly — $128.46
Biweekly — $256.92
Monthly — $556.67
51
Medical Assistant - 4 Months - Payment Options
Please Select
Please Select
Weekly — $105.00
Biweekly — $210.00
Monthly — $455.00
52
Medical Assistant - 5 Months - Payment Options
Please Select
Please Select
Weekly — $90.92
Biweekly — $181..85
Monthly — $394.00
53
Multi Medical Assistant - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
4 Months
5 Months
6 Months
54
Multi Medical Assistant - 4 Months - Payment Options
Please Select
Please Select
Weekly — $174.23
Biweekly — $348.46
Monthly — $755.00
55
Multi Medical Assistant - 5 Months - Payment Options
Please Select
Please Select
Weekly — $150.58
Biweekly — $301.15
Monthly — $654.00
56
Multi Medical Assistant - 6 Months - Payment Options
Please Select
Please Select
Weekly — $135.38
Biweekly — $270.77
Monthly — $586.67
57
Dental Assistant - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
5 Months
6 Months
7 Months
58
Dental Assistant - 5 Months - Payment Options
Please Select
Please Select
Weekly — $145.38
Biweekly — $290.77
Monthly — $630.00
59
Dental Assistant - 6 Months - Payment Options
Please Select
Please Select
Weekly — $132.69
Biweekly — $265.38
Monthly — $575.00
60
Dental Assistant - 7 Months - Payment Options
Please Select
Please Select
Weekly — $123.63
Biweekly — $247.25
Monthly — $535.71
61
Surgical Technology - Extended Payment DurationHow long you would like to extend your payment out.
Please Select
Please Select
9 Months
10 Months
11 Months
62
Surgical Technology - 9 Months - Payment Options
Please Select
Please Select
Weekly — $108.97
Biweekly — $217.95
Monthly — $472.22
63
Surgical Technology - 10 Months - Payment Options
Please Select
Please Select
Weekly — $106.15
Biweekly — $212.31
Monthly — $460.00
64
Surgical Technology - 11 Months - Payment Options
Please Select
Please Select
Weekly — $103.85
Biweekly — $207.69
Monthly — $450.00
65
ProgramTerm1
66
ProgramTerm2
67
ProgramTerm3
68
Enrollment Link
Should be Empty: