SISTUHSNational Dues Payment Extension Request Form
Member Name:
*
First Name
Last Name
Date:
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment:
*
1st Installment
2nd Installment
Length of Extension Requested:
*
30 Days
45 Days
60 Days
Chapter Affiliation:
*
Bethune-Cookman University
Broward County Professional
Central Florida Professional
Florida A&M University
Florida Atlantic University
Florida Gulf Coast University
Florida International University
Florida Memorial University
Florida State University
Kennesaw State University
Metro-Atlanta Professional
Miami Professional
North Florida Professional
Tampa, Fl Professional
University of Central Florida
University of Florida
University of South Florida
Valdosta State University
Reason for Request:
*
Delay in Financial Aid
Loss of Job
Unexpected Financial Obligation
Other explanation text
*Please note that this is just a request. Completion of this form does not guarantee that an extension will be granted or that late fees will not be assessed. If granted, a specific time period will be allotted for a Member to pay their National Dues. Please attach any documentation necessary justifying the reason for your request. You will be notified in writing by your Chapter Treasurer if your request has been approved or denied. It is your responsibility to follow up on the status of your request with your Treasurer.
*By signing this form, you are agreeing that all of the information you have provided is truthful to your knowledge, and you understand that failure to provide truthful information on this form will result in consequences determined by the National Board of Directors of SISTUHS, Incorporated.
Member Signature
*
Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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