The Catholic University of America s3

THE CATHOLIC UNIVERSITY OF AMERICA Application for Tuition Assistance for Employees

Please provide all of the information requested below. Incomplete applications will be returned to you for completion. Deadline: Last day to add/drop courses for each semester.

SECTION 1: Employee Information Name: ID #:

Department/Office: Position:

Campus Telephone: Hire Date:

I am: Full-time Faculty Full-time Staff Part-time Staff If part time: Hrs Per Week SECTION 2: Course Information I am requesting the Tuition Assistance Benefit for myself in The Catholic University of America’s: School of Arts & Sciences School of Business & Economics School of Theology & Religious Studies School of Philosophy School of Architecture & Planning School of Engineering School of Music Metropolitan School of Professional Studies School of Canon Law Columbus School of Law NCSSS School of Nursing Intensive English Other *Employees are eligible to receive tuition assistance for 4 courses each academic year, not to exceed 2 courses in a semester. For the Fall Spring Summer Semester. (Year) I am requesting Tuition Assistance for ONE TWO Course(s) for a total of Credits

My course is: Undergraduate Graduate Class Standing: FR SO JR SR MAST DOC Non-degree seeking SECTION 3: Employee’s Certification YES NO  I understand that if my employment with the University terminated prior to the completion of the semester specified above, the full amount of tuition charges for the semester will become due immediately, subject to any exceptions permitted by University Policies on tuition assistance benefits.  I understand that employee tuition benefits may not be combined with other University scholarships or funds.  I understand that employees are eligible to receive tuition assistance for themselves for four (4) courses each academic year, not to exceed two (2) courses in a semester. (Graduate students in MSPS should review TA Policy).

Signature of Employee: Date: Is course held during normal working hours? *YES NO (if no, no other signatures are required.) *If course is held during normal working hours, approval from immediate supervisor and cognizant Vice President is required prior to submission to Human Resources. A copy of the agreed upon alternative working schedule must also be provided. Approved by: Date: *Immediate Supervisor Approved by: Date: *Vice President

SECTION 4: Office of Human Resources Approval Tuition assistance approved for: $ Reviewed/Approved by: Date:

THIS FORM MUST BE SUBMITTED TO THE OFFICE OF HUMAN RESOURCES BY THE LAST DAY TO REGISTER, ADD, OR DROP CLASSES AS LISTED IN ANNOUNCEMENTS. Office of Human Resources, Rev. 08/2013