Academic Tuition Assistance Program
1-61000-28 (Revised 09/2008)
ACADEMIC TUITION ASSISTANCE PROGRAM FORM
Name__________________________ Employee ID # _________________
Waiver Hours Requested _______ Semester ________
Course
Number
Prefix Class Time
Schedule
Days
Attach a description of the employee’s Revised Work Schedule, (if course is scheduled
during employee’s regular work hours). This schedule must be signed by employees’
supervisor.
By signing below, I affirm that:
• the cumulative GPA since entrance into this program exceeds 2.5 GPA;
• Courses requested to be waived herein have not been audited or previously
enrolled;
• All class related activities will be performed outside normal work hours.
_________________________ ______________________________
Employee Signature Date
_________________________ ______________________________
Supervisor’s Signature Date
_________________________ ______________________________
Vice President Approval Date
_________________________ ______________________________
Coordinator, Employment & Benefits Date
