APPLICATION FOR EDUCATIONAL AID FOR …

1 APPLICATION FOR EDUCATIONAL AID FOR quinnipiac EMPLOYEESGROUP Administrative Clerical 10M 12 MFaculty Full-Time Health Center ____wks ____ hrs Student ID # Maintenance Radio Station Public SafetyPT Faculty ____ # Credits Pursuant to the EDUCATIONAL Benefit policy of quinnipiac University for all full-time and part-time employees, the employee whose name and signature appears below hereby applies for EDUCATIONAL aid. Employees who separate from the University will receive a prorated benefit amount. Tuition remission does not apply to all programs and degree levels. Questions regarding eligibility and programs covered should be directed to human resources. Employee Name: Date of Hire: Full Time Part Time Department: Relationship (If not self): Spouse* Non-Dependent Child Supervisor/Chairman: Dependent Child* Age: Name of Student: Shift Hours: Course Level/School: Graduate** Undergraduate Law School Degree Program: *Spouse/dependent eligibility verification must be submitted upon initial waiver request**The IRS requires that taxes are withheld on graduate courses in certain circumstances.

2 Academic Year: Semester: Fall Spring Summer I Summer II J-Term All students continuing in a program are required to submit an unofficial transcript AND copy of course registration (available on WebAdvisor) New students are not required to submit transcripts. If you are a new student (first time enrollee), please check here . ALL COURSE INFORMATION MUST BE COMPLETED IN THE SPACE PROVIDED BELOW. Courses Time/Day Semester Hours **Registration must be for the courses listed. Please contact HR for any change in registration or registration for courses not listed.** _____ _____ Employee Signature Date Supervisor/Chairman Signature Date (required only when employee is the student) For Human Resources/Bursar Use Only Fee Type Amount _____% AR Department Charge Percentage Tuition: 10- -81989 % Registration Fee: 10- -81989 % Student Fee: 10- -81989 % Course Fees: _____ Total Charges Less Amount Waived: HR Administrator Date Total Due and Payable by Employee: PTF # of CRDTS: TRANSCRIPT REQ SUB ELIGIBILITY REQ SUB X