Agency Name

Agency Website

Agency Address

Address Line 1

Address Line 2

City

State

ZIP Code

Agency Contact Person's Name

First Name

Last Name

Agency Contact Person's Email Address

Confirm Email Address

Agency Contact Person's Phone Number

Agency Description

Please provide a short description of your agency’s work and mission and explain how you would benefit from this initiative. Please be sure to include any current student loan or financial literacy work you are doing.

Does your agency currently provide (check all that apply):

Student Loan ServicesFinancial Counseling Services

Other service(s) provided by your agency:

Number of individuals from your agency interested in participating.

What level of student loan knowledge do the expected participants have? (Check all that apply)

BeginnerIntermediateExpert

Commitment and Disclaimer

We expect that participants who are selected will agree to actively engage in our training sessions, attend regular monthly meetings, and maintain ongoing involvement as part of the network’s initiatives and activities. By submitting this form, you acknowledge that participation in the National Student Debt Counselors Network is voluntary. CSS reserves the right to select agencies based on their commitment to the network’s goals and the capacity to effectively support student loan borrowers.

Signature

Name of person submitting this form.

Date