ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 1
Virginia Wesleyan University Office
of Finance and Administration
5817 Wesleyan Drive
Virginia Beach, VA 23455
757-455-3280
ROBERT NOYCE TEACHER SCHOLARSHIP
APPLICATION PACKET
A forgivable loan program
Please read all provided instructions, and then complete and submit the following (3) documents together to the Student Accounts Office
(submission instructions are provided at the bottom of this page):
• Noyce Promissory Note (3 pages) This form is included in this packet.
• Statement of Rights & Responsibilities (2 pages) This form is included in this packet.
• Student Loan Worksheet (2 pages) This form is included in this packet.
Because you are entering into a legal and binding student loan repayment agreement a Promissory Note must be completed for each year,
all information requested is required without exception. The most common mistakes made on these forms are:
• Answering Worksheet questions with, “N/A” (this is never an acceptable response);
• Leaving a W
orksheet line blank; and
• Illegible writing, or completing and signing in pencil.
The two page Student Loan Worksheet must be completed with acceptable responses. Please use the information provided
below as a guide:
BORROWER INFORMATION:
• All requested information is required except cell phone. However,
including it is recommended, as it can help in our efforts to keep your
account current.
• T
he complete Social Security Number is required on each document.
• We w
ould prefer that you provide your personal email address on this
document, not your VWU assigned email address. However, if you do
not have a personal email address, please provide the VWU assigned
address. • If you do not have a local address, you may answer “same as
permanent address” in the local address section.
SPOUSAL INFORMATION:
• I
f you answered “yes” to question (3), please complete this section.
O
therwise, leave it blank.
BORROWER’S PARENTAL INFORMATION:
• No matter your age, unless a parent i
s deceased, or you have no
contact, this information is required (do not leave the line blank.
Please respond with Deceased, No Contact, Ward of the Court, etc.).
Your parents will never be expected to repay your loan. The
information is used for contact purposes only (if we cannot reach you
at an address you have provided, we will contact the parent for
assistance).
• If your parents are divorced, you still need to reference both.
• P
lease refer to the Employer Responses section for additional
information.
SPOUSE’S PARENTAL INFORMATION:
• If you are not married you may le
ave this section blank.
Otherwise, the information is required. Please refer to the
Bo
rrower’s Parental Information section (above) for assistance.
REQUIRED REFERENCE INFORMATION:
• All references must be at least 18 years of age; reside in the United
States; and have a home address & phone number.
Unless the reference you are listing is a relative, the reference cannot be
a VW
U staff member or current VWU student.
• No reference you list can have the same home address or phone
nu
mber as you, your parents, or other references listed.
• If the reference is attending college (other than V
WU), please use the
reference’s permanent home address, NOT the school address.
• References CAN have the same employer.
E
MPLOYER RESPONSES:
• If employed, all information is required.
• If a student, indicate school of attendance.
• If unemployed, please indicate.
• If self-emp
loyed, please indicate – and include cell phone #.
DO NOT:
• Do not leave a line blank, unless instructed to do so.
• Do not sign any document in pencil.
• Do not use “N/A” on any line.
• Do not cross through a line.
• Do not forget the zip codes.
APPLICATION SUBMISSION INSTRUCTIONS:
You are required to submit original documents. You may do
so
by handing them in, or mailing them to the Office of
Finance and Administration (address provided at the top of
this form).
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 2
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE For internal use:
A forgivable loan lent by Virginia Wesleyan University Award amount:
$
Section A: Scholarship Recipient/Borrower Section
1. Name (Last, first, middle initial)
and Permanent Address (street, city, state, zip code)
2. Social Security Number
3. Date of Birth (mm/dd/yyyy)
4. Home Area Code/Telephone Number
5. Driver’s License Number (list state abbreviation first)
Section B: School/Lender Section
6. School/Lender Name & Address (street, city, state, zip code)
Virginia Wesleyan University
Office of Finance and Administration
5817 Wesleyan Drive
Virginia Beach, VA 23455
7. Annual Fixed Interest Rate
5%
8.
Billing Service Information (where to make payments & provide address
changes and other information)
Virginia Wesleyan University
Office of Finance and
Administration
Terms and Conditions: (Note: Additional Terms and Conditions follow on pages 2 & 3 of this Promissory Note - hereinafter called
the Note).
GENERAL TERMS - The Robert Noyce Scholarship program awards scholarships to juniors and seniors and graduate students at
Virginia Wesleyan University (the “School” or “VWU”) who are majoring in biology, chemistry, earth and environmental science, or
mathematics, who are seeking to become 6-12 biology, chemistry, earth and environmental science, or mathematics teachers in high-need
school districts. A Noyce Scholarship recipient (the student who received the award) must complete two years of teaching service (per
program guidelines) for each year the Noyce funds were awarded. This teaching service must be completed within eight years after
graduating from the academic program for which the Noyce funds were awarded. The Noyce award will be considered a loan that must
be repaid according to the terms of this Note if (1) the recipient fails to satisfy the academic requirements of the academic program for
which the Noyce funds were awarded; or (2) the recipient fails to complete the teaching service requirement. This program is monitored
by Dr. Claire Berube and Dr. William McConnell (“the Monitors”), professors in the D. Henry Watts School of Professional Studies,
who requested and are administering these funds from the National Science Foundation. If they are no longer at VWU, The Dean of D.
Henry Watts School of Professional Studies shall serve as a Monitor.
GENERAL NOYCE SCHOLARSHIP AWARD QUALIFICATIONS – Scholarship awards will be $23,000 per year in the student's
junior and senior years and $21,000 during the year of the MAEd program; however, no individual may receive a scholarship for any year
that exceeds the yearly cost of attendance (as defined in section 472 of the Higher Education Act of 1965 (20 U.S.C. 1087ll)).
Scholarship recipients must be a) U.S. citizens or nationals, or permanent resident aliens; 2) majoring in a biology, chemistry, earth and
environmental science, or a mathematics discipline; 3) in the last 2 years of a baccalaureate degree program, or 4) enrolled in VWU’s
MAEd Program.
CHANGE OF STATUS – I will inform the School’s billing service, the VWU Office of Finance and Administration, and the
Monitors within 10 days of any change in my name, address, telephone number, Social Security Number, or driver’s license
number.
EXIT INTERVIEW REQUIREMENT – I am required to complete an exit interview (made available by the school) within one month
of leaving the School (graduating from my academic program, or dropping below full-time enrollment – whichever occurs first).
REPAYMENT GUIDELINES– I will be expected to begin repaying my Noyce Scholarship beginning thirty-one (31) days after failing
to meet any of the requirements for which the Noyce funds were awarded. These requirements include:
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 3
• Maintaining enrollment with a GPA of at least 2.8 in the program for which the Noyce funds were awarded;
• Graduating from the program for which the Noyce funds were awarded;
• Successful participation in all semi-annua
l and annual submission of demographic/employment/education related survey
information associated with the Noyce Scholarship program.
• Meet the service requirement of completing 2 years of teaching for each Noyce Scholarship award year within 8 ye
ars of
graduating.
I will be expected to begin repaying my Noyce Scholarship beginning thirty-one (31) days after declaring that I do not intend to fulfill the
service requirement.
LOAN CANCELLATION (SERVICE CREDIT) – To cancel each year’s Noyce Scholarship award, I understand that under this Note I
am required to complete two years of service as a biology, chemistry, earth and environmental science, or mathematics teacher in a high
need school district that meets one or more of the following criteria: (A) It has at least one school in which 50 percent or more of the
enrolled students are eligible for participation in the free and reduced price lunch program established by the Richard B. Russell Nation
School Lunch Act (42 U.S.C. 1751 et seq.); (B) It has at least one school in which: (i) more than 34 percent of the academic classroom
teachers at the secondary level (across all academic subjects) do not have an undergraduate degree with a major or minor in, or a graduate
degree in, the academic field in which they teach the largest percentage of their classes; or (ii) more than 34 percent of the teachers in two
of the academic departments do not have an undergraduate degree with a major or minor in, or a graduate degree in, the academic field in
which they teach the largest percentage of their classes; (C) It has at least one school whose teacher attrition rate has been 15 percent or
more over the last three school years. A school year is defined as two academic semesters.
To apply for Noyce Scholarship award cancellation the School requires that I submit a completed Request for Cancellation form prior to
my teaching service to VWU Office of Finance and Administration and to the Monitors, and at the end of my teaching service, for every
year of service. If I do not satisfy the academic requirements of the program for which the Noyce Scholarship funds were awarded,
I will not be eligible for the loan cancellation benefit.
EXTENSION OF POST-GRADUATION SERVICE CREDIT PERIOD – If I experience unexpected hardship that prevents me from
taking a teaching position, I may request from the Monitors an extension of time to complete my eight year post-graduation service
credit.
PREPAYMENT - I may prepay all or any part of my unpaid loan balance, plus any accrued interest, at any time without penalty.
Amounts I repay in excess of the amount due for an installment shall be used to repay principal unless I designate it as an advance
payment of the next regular installment. I will not prepay on the loan unless I am in repayment status; if I later perform service credits for
loan forgiveness, payments towards the loan will not be refunded.
INTEREST – Interest on this loan shall accrue from the beginning of the repayment period. My annual fixed interest rate is 5%.
MINIMUM MONTHLY PAYMENT – The School sets $150 as the minimum monthly payment amount and up to 10 years to repay
my obligation. But my repayment period may be shorter than 10 years based on the minimum monthly payments and the amount that I
owe. The School may round my installment payment to the next highest multiple of $5.
LATE CHARGES – The School may impose late charges if I do not make a scheduled payment when due or if I fail to submit to the
VWU Office of Finance and Administration, on or before the due date of the payment, a properly documented request for any of the
forbearance or deferment benefits as described in the Note. No late charges may exceed 20 percent of my monthly payment. The School
may add the late charges to the principal the day after the scheduled payment was due or include it with the next scheduled payment after
I have received notice of the charge, and such notice is sent before the next installment is due.
FORBEARANCE OF REPAYMENT PERIOD– Upon making a timely and properly documented written request to the VWU Office
of Finance and Administration, I am entitled to forbearance of principal only, renewable at intervals of up to 12 months for periods that
collectively do not exceed three years if my monthly loan debt (including Title IV loans) exceeds 20 percent of my total monthly gross
income. Interest accrues during any period of forbearance. My repayment period may be extended during periods of forbearance.
DEFERMENT OF REPAYMENT PERIOD– To apply for a deferment, I must request the deferment from the VWU Office of Finance
and Administration. The School requires that I submit supporting documentation to prove my eligibility for a deferment. Deferment: I
understand that I will not be considered in violation of the repayment schedule if I promptly request a deferment in writing and am
granted a deferment during the time that I am:
1. Serving, not in excess of three (3) years, on active duty as a member of armed services of the United States.
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 4
2. Te
mporarily disabled, for a period not to exceed three (3) years, as established by sworn affidavit of a qualified physician.
3. Una
ble to secure or continue employment as a teacher in a qualifying school for a period not to exceed twelve (12) months by reason
of t
he care required by a spouse who is disabled.
4. Actively seeking and unable to find employment as a physics, chemistry, mathematics, computer science, engineering/engineering
tec
hnology, and/or physical science teacher in a qualifying school for a period not to exceed twenty-four (24) months prior to initial
employment, or for a period not to exceed twenty-four (24 months) after initial employment.
Interest does not accrue for any periods of deferment. My regularly scheduled payments will resume 1 month after my deferment period
expires. My repayment period may be extended during periods of deferment.
DEFAULT WHILE IN REPAYMENT– The School may, at its option, declare my loan to be in default if (1) I fail to make a scheduled
payment when due; (2) I fail to submit to the VWU Office of Finance and Administration on or before the due date of the scheduled
payment, documentation that I qualify for forbearance or deferment; (3) I fail to comply with the terms and conditions of this Note or
written repayment agreement. I will be ineligible for any further institutional loan funds, and may be denied further federal student
financial assistance authorized under the Higher Education Act of 1965 (hereinafter called the Act), as amended, until I make
arrangements to repay my loan that are satisfactory to the School. The School shall disclose to credit bureau organizations that I have
defaulted and all other relevant loan information. I will lose my right to defer payments and my right to forbearance if I default on my
loan. The School may accelerate my defaulted loan. Acceleration means that the School demands immediate payment of the entire unpaid
balance of the loan, including principal, interest, late charges, and collection costs.
MONITOR-APPROVED LEAVE OF ABSENCE – If I must take a leave of absence for health reasons prior to the completion of the
biology, chemistry, earth and environmental science, or mathematics program or teacher certification, I must submit proof of
schoolapproved medical leave of absence to the Monitors. When I re-enroll at VWU I will be eligible to reapply for the Noyce
Scholarship. If I do not re-enroll at VWU within 3 quarters or do not continue in the biology, chemistry, earth and environmental
science, or mathematics program, repayment will commence. Upon request to the Monitors, I may perform service credit for that
portion of the Noyce Scholarship that was awarded to me.
TRANSFER TO ANOTHER SCHOOL TO ANOTHER BIO / CHEM / ENVIRON. EARTH SCI. / MATH / TEACHER
PROGRAM – If I transfer to another school to another math or a teacher certification program, I will not receive further Noyce
Scholarship funds, but upon request to the Monitors, I may perform service credit for that portion of the Noyce Scholarship that was
awarded to me after graduation. If I re-enroll at VWU I will be eligible to reapply for the scholarship. If I do not enroll in any other
biology, chemistry, earth and environmental science, or mathematics program or a teacher certification program within 3 quarters of
dropping below full-time enrollment at VWU and show written documentation of such continuing enrollment to the Monitors,
repayment will commence.
DISCHARGE OF LOAN - My obligation to repay this loan may be partially or totally discharged (A) in the event of my death, the
School will discharge the total amount still owed on this loan; (B) If I become totally and permanently disabled after I receive this loan,
the School will discharge the total amount still owed on this loan; (C) extreme hardship, such that deferment and forbearance options
are extremely unreasonable and any options under this agreement have been exhausted, (D) under certain conditions, this loan may be
discharged in bankruptcy. In order to discharge this loan in bankruptcy, I must prove undue hardship in an adversary proceeding before
the bankruptcy court.
PRIVACY ACT NOTICE – This loan, and all subsequent loans, are being awarded and disbursed to assist with educational related
expenses. As such, it falls under the Family Education Rights & Privacy Act (FERPA)
PROMISE TO PAY: I understand that under this Note, I am required to repay monetarily, or through stated service options, the sum of
all disbursements, plus associated fees which may become due (where applicable). I understand that each loan is separately enforceable
based on a true and exact copy of this Note. I understand that I may cancel or reduce the amount of any loan by not accepting or by
returning all or a portion of any disbursement that is issued. If I do not make any payment on any loan under this Note when it is due, I
promise to pay all reasonable collection costs, including attorney fees, court costs, and other fees. I will not sign this Note before
reading the entire Note, even if I am told that I am not required to read it. I am entitled to an exact copy of this Note and in signing this
Note am acknowledging that I have received one. It is my responsibility to download a copy of this contract and submit an executed
copy to the School prior to any disbursement to me, and to maintain a copy for my files. This loan has been made to me without security
of endorsement. My signature certifies that I have read, understand, and agree to the terms and conditions of this Note. Any disclosure,
or Truth In Lending, statement I receive in connection with any loan under this Note is hereby incorporated into this Note.
I UNDERSTAND THAT THIS IS A LOAN THAT MUST BE REPAID.
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 5
Borrower’s Signature Date
STATEMENT OF RIGHTS & RESPONSIBILITIES
Robert Noyce Scholarship Program
Page 1 of 2
A f
orgivable loan lent by Virginia Wesleyan University
Noyce Scholarship Loan Lender:
Virginia Wesleyan University
Office of Finance and Administration
5817 Wesleyan Drive
Virginia Beach, VA 23455
757
-455-3280
finance@vwu.edu
Noyce Loan Billing Service:
Virginia Wesleyan University
Office of Finance and Administration
5817 Wesleyan Drive
Virginia Beach, VA 23455
I understand that (please initial each line item):
1) The Robert Noyce Scholarship funds are being awarded to me as a forgivable loan. If I do not satisfy the academic and
service requirements as outlined in my Promissory Note I will be required to repay the Noyce funds, plus any and all associated interest and
fees.
2) I will be required to begin repaying the Noyce scholarship funds awarded within thirty-one days of failing to satisfy the
requirements of the academic program for which the funds were awarded. The academic requirements include: 1)
Maintaining at least full-time enrollment each term with a GPA of at least 2.8 until graduating from the academic program; 2)
Graduating from the academic program for which the Noyce funds were awarded; and 3) Successful participation in all semi-
annual and annual submission of demographic/employment/education related survey information associated with the Noyce
Scholarship program: a) During my continued enrollment in my academic program; and b) And after graduating from the
academic program.
3) If I fail to meet the academic and/or survey requirements of the Noyce Scholarship program for which the funds were
awarded, I automatically forfeit the cancellation benefit, and all Noyce funds that were disbursed to me are due and payable
according to the terms of my Promissory Note.
4) I have eight years beyond graduating from the academic program for which my Noyce Scholarship funds were awarded to
satisfy the service requirement. The service requirement consists of working as a biology, chemistry, earth and environmental
science, or mathematics teacher as outlined in my Promissory Note, with one year’s Noyce scholarship award being cancelled (forgiven) for
every 2 years of teaching service. I am responsible for successfully submitting proof of teaching before the teaching period and immediately
following the teaching period – for every year of teaching. I understand that the Request for Cancellation form is available through the
billing service, the VWU Office of Finance and Administration. Noyce Scholarship funds not cancelled within the eight-year window must
be repaid. Repayment will commence 8 years and thirty-one days after I graduate from the academic program for which the funds were
awarded.
5) VWU and/or its billing service DOES report all repayment information to at least one major credit bureau. Accurately
reported information is NOT negotiable, even after the loan has been paid in full.
6) If I am expected to repay the Noyce program funds. I understand that there is never a prepayment penalty. I may make
payment in excess of the amount expected at any time. Unless otherwise notified, any amounts received in excess of the
amount expected will be applied to the principal balance and WILL NOT take the place of my regularly scheduled payments.
7) In my last quarter of full time enrollment I must arrange for my REQUIRED student loan exit interview. I will do so by
contacting Virginia Wesleyan University's Office of Finance and Administration. Failure to complete the exit interview
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 6
process as requested will result in VWU withholding all services until the loan is paid in full, or the exit interview process is completed –
whichever comes first.
8) My loan may be subject to late fees of up to 20% of the past due installment.
STATEMENT OF RIGHTS & RESPONSIBILITIES
Robert No
yce Scholarship Program
Page 2 of 2
A
forgiva
ble loan lent by Virginia Wesleyan University
9) I must, without exception, notify the VWU Office of Finance and Administration within 10 days if (A) I withdraw from
VWU; (B) m
y name should change (I will need to provide verification of the change) ; (C) I drop below full time units;
(D) my billing address and/or phone number should change (do not rely on the Post Office’s Address Change form,
CONTACT THE VWU OFFICE OF FINANCE AND ADMINISTRATION DIRECTLY); or (E) I think I’m eligible for
a deferment or forbearance (forms should be requested and eligibility determined by the VWU Office of Finance and
Administration.
10) The VWU Office of Finance and Administration will attempt to notify me with information related to my
disbursements; my exit interview requirement; and loan repayment information. I understand that it is my responsibility – even during
enrollment at VWU – to maintain a current address and phone number on my VWU loan account.
11) If I fail to pay my loan as agreed, I will no longer have access to VWU services (records & enrollment); my loan will be
assigned to a collection agency, and may be accelerated (loan balance due and payable IN ITS ENTIRETY); all loan benefits
will no longer be available to me; and I will be required to pay all collection, court, and attorney’s fees if my loan becomes, or continues to
be, past due.
12) If I allow my loan to be more than 90 days past due, it will be considered in default, and such a status may compromise my
ability to receive future Title IV funds, or additional institutional loan funds, through VWU, until such time as the defaulted
loan is paid in full. Further, VWU will withhold all services until such time as the loan is paid in full.
13) I am expected to contact the VWU Office of Finance and Administration, BEFORE THE DUE DATE, if I cannot make
my payment on time. VWU will withhold all services until my delinquent (late)/defaulted loan account has been brought current
and/or paid in full.
14) I understand that whether or not I receive my monthly billing statement, my payment is due on time. I further understand
that I am expected to promptly answer all communications – written or otherwise – from the VWU Office of Finance and
Administration.
15) I authorize VWU access to any and all of my demographic, contact, enrollment, and employment information from any
third party for purposes of enforcing the terms and conditions of any Noyce Scholarship repayment obligation I might
incur.
I attest that I have read and understand my repayment responsibilities and the options available to me. As outlined in the Promissory Note,
I understand that if I do not fulfill the Noyce academic and service requirements, the Noyce scholarship funds disbursed to me will
convert into a loan that must be repaid. This loan must be repaid in a timely manner as called for in my Promissory Note. The payment
terms associated with this loan program were mutually agreed upon between me and my lending institution, Virginia Wesleyan
University. In signing below I acknowledge that I have printed out an exact copy of this form, and that said copy will be considered the
“borrower’s copy”.
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 7
Print Full Name Signature Date of Signature Social Security Number
BORROWER INFORMATION:
1. NAME: FIRST MIDDLE LAST
2. DATE OF BIRTH: (MO/DAY/YEAR)
3. MARTIAL STATUS:
SINGLE MARRIED
4. SOCIAL SECURITY NUMBER
5. DRIVER’S LICENSE OR STATE IDENTIFICATION
CARD
STATE: NUMBER:
6. LOCAL (SCHOOL) ADDRESS. IF YOU DON’T HAVE ONE YET, COMPLETE
PERMANENT ADDRESS ONLY.
7. PERMANENT MAILING ADDRESS. REFERENCE AN ADDRESS WHERE YOU CAN
ALWAYS GET YOUR MAIL
CITY STATE ZIP
CITY STATE ZIP
8. REQUIRED PHONE NUMBERS:
LOCAL AT SCHOOL ( WITH AREA CODE)
PERMANENT (WITH AREA CODE)
WORK (WITH AREA CODE & EXTENSION)
9. MORE REQUIRED INFORMATION:
E-MAIL ADDRESS (PLEASE PROVIDE YOUR PERMANENT EMAIL ADDRESS, NOT YOUR
SCHOOL EMAIL)
CELL PHONE ( WITH AREA CODE)
10. BORROWER’S EMPLOYER, NAME OF COMPANY AND COMPLETE MAILING ADDRESS
SPOUSE INFORMATION: IF YOU ARE NOT MARRIED SKIP TO QUESTION #15
STUDENT
LOAN WORKSHEET
2
page document
For
The
Robert
Noyce Scholarship
lent by
Virginia Wesleyan University
COMPLETE
BOTH
PAGES
OF
THIS
WORKSHEET
AND
SUBMIT
WITH
SUPPORTING
DOCUMENTS
(
SEE
PAGE
ONE)
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 8
11. NAME: FIRST
MIDDLE LAST
12. DATE OF BIRTH: (MO/DAY/YEAR)
13. SOCIAL SECURITY NUMBER
14. IS YOUR SPOUSE ATTENDING SCHOOL?
NO YES
IF “YES” WHERE? NAME, CITY & STATE OF SCHOOL
BORROWER’S PARENTAL INFORMATION: (REQUIRED)
15. FATHER: NAME: FIRST
MIDDLE LAST
FATHER’S EMPLOYER
MAILING ADDRESS
EMPLOYER’S MAILING ADDRESS
CITY STATE
ZIP PHONE NO. WITH AREA CODE
CITY STATE
ZIP
PHONE NO. WITH AREA
CODE
16. MOTHER: NAME: FIRST
MIDDLE LAST
MOTHER’S EMPLOYER
MAILING ADDRESS
EMPLOYER’S MAILING ADDRESS
CITY STATE
ZIP
PHONE NO. WITH AREA CODE
CITY STATE
ZIP
PHONE NO. WITH AREA
CODE
ROBERT NOYCE SCHOLARSHIP Worksheet Page 1
REFERENCES: Please review page 1 of this packet for more information.
19. List two (2) relatives, other than your parents, who will always know your address. You may use close family friends if you do not have relatives
with U. S. addresses. Each reference must have a different home address and phone number and they cannot be the same as yours, your parents, or any other
reference listed. References must be at least 18 years old and cannot be current VWU staff or students.
1. RELATIVE REFERENCE NAME
HOME: AREA CODE & PHONE
NO.
EMPLOYER NAME
EMPLOYER: AREA CODE & PHONE
NO.
HOME: MAILING ADDRESS
CITY
STATE
ZIP
2. RELATIVE REFERENCE NAME
HOME: AREA CODE & PHONE
NO.
EMPLOYER NAME
EMPLOYER: AREA CODE & PHONE
NO.
HOME: MAILING ADDRESS CITY STATE ZIP
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 9
20. List three (3) references, other than VWU students, staff, or previously listed references who will always know your address. Each reference
must have a different home address and phone number and they cannot be the same as yours, your parents, or any other reference listed. References must
be at least 18 years old.
1. REFERENCE NAME
HOME: AREA CODE & PHONE NO.
EMPLOYER NAME
EMPLOYER: AREA CODE & PHONE NO.
HOME: MAILING ADDRESS
CITY
STATE ZIP
2 REFERENCE NAME
HOME: AREA CODE & PHONE NO.
EMPLOYER NAME
EMPLOYER: AREA CODE & PHONE NO.
HOME: MAILING ADDRESS
CITY
STATE ZIP
3. REFERENCE NAME
HOME: AREA CODE & PHONE NO.
EMPLOYER NAME
EMPLOYER: AREA CODE & PHONE NO.
HOME: MAILING ADDRESS CITY STATE ZIP
I certify that to the best of my knowledge the information provided is true and correct. I acknowledge that I am receiving a loan that must be repaid, and that I
am required to notify VWU, and the VWU Office of Finance and Administration, of all changes until the loan is paid in full. I understand that my failure to
repay this loan as outlined in the promissory note terms and conditions will result in VWU withholding all University services until my loan delinquency is
resolved.
BORROWER’S SIGNATURE DATE OF SIGNATURE
Virginia Wesleyan University
Office of Finance and Administration
5817 W
esleyan Drive
Virginia Beach, Virginia 23455
757-455-3280
REVIEW YOUR FORMS BEFORE SUBMISSION
Make sure you review all your forms and submit them together. Incomplete forms will be rejected.
The
funds will not disburse until the application packet has been successfully submitted to the Office
of Finance and Administration.
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 10
Rob
ert Noyce Promissory Note (3 page document):
- You must complete items 1 through 5 on the Promissory Note.
- Make sure you read the information provided on the Promissory Note. Let your loan counselor
know if you have questions: [email protected]du
- Sign and date the Promissory Note. Keep a copy for your records.
- You wi
ll need to complete a new Promissory Note each year you are enrolled in this program.
Statement of Rights & Responsibilities (2 page document):
- Make sure you read the information on the Statement of Rights & Responsibilities and initial
each line item. Let your loan counselor know if you have questions: finance@vwu.edu
Student Loan Worksheet (2 page document):
- Make
sure you read over the instruction page that is included in this packet.
- Prov
ide all required information and sign and date the bottom of the second page.
Rob
ert Noyce Application Packet Submission Instructions:
You must submit your completed forms together:
Prom
issory Note (3 pages)
Statement of Rights & Responsibilities (2 pages) Student Loan
Worksheet (2 pages)
Ori
ginal documents are required. Please hand deliver, or mail your completed forms to Virginia
Wesleyan University’s Office of Finance and Administration using the address provided at the
top of this form.
ROBERT NOYCE SCHOLARSHIP PROMISSORY NOTE Page 11
