GROWTH THROUGH LIFEAPPLICATION

FACULTY/STAFF DEVELOPMENT PROGRAM – TUITION GRANT

Effective: August 1, 2016

Quarter (Check One): Fall______Winter ______Spring _____ Summer _____

ATTACH MOST RECENTGRADE TRANSCRIPT INCLUSIVE OF CUMULATIVE GPA TOTAL

APPLICATION FOR INTERNAL PROGRAM MUST BE COMPLETED AND SUBMITTED TO HR PRIOR TO END OF BUSINESS DAY TUESDAY, WEEK 7

Staff Faculty FAC & Staff –(External Program)

Dependent/Domestic Partner Dependent/Domestic Partner

Complete this section if employee is requesting GTL benefits.

FACULTY OR STAFF (EMPLOYEE)

Name (print) ______Last four digits of Social Security #______

Job Title______Department______

Complete this section if dependent/domestic partner is requesting GTL benefits.

DEPENDENT/DOMESTIC PARTNER

Employee Name: ______Last four digits of Social Security #:

Job Title: ______Department: ______

Dependent Name: ______Last four digits of Social Security #:______

Relationship to Employee: Dependent Child’s Date of Birth______

I am applying for the Tuition Grant benefit identified for the above-noted quarter and make the following representations. All Faculty and Staff employees and their dependent family members must meet the following criteria, and additionally meet the criteria applicable to their specific status.

I understand by applying for the Growth Through Life benefit that I’m choosing to receive the Growth Through Life employee benefit and forego my rights to federal/state aid. EMPLOYEES ARE NOT ELIGIBLE TO RECEIVE BOTH TUITION BENEFIT AND FEDERAL/STATE FINANCIAL AID. I acknowledge I have read the Growth Through Life policy and agree to abide by all the terms of the policy.

CHECK ONE OF THE FOLLOWING TO INDICATE PROGRAM:

_____ Pursuing Degree (Must make application to Life University Admissions Department)

Indicate Degree Type: ______Anticipated Graduation Date: ______

_____ Courses being taken for personal/professional development

LISTANTICIPATED COURSES:

Course Title: Course No. Time & Day:______

Course Title: Course No. Time & Day:______

I will notify the appropriate College if a conflict arises so that I can rescind and dis-enroll.

Employee Signature:______Date:______

Supervisor’s name:______Date:______

(Print Name)

This employee has my permission to enroll in the courses for the quarter noted above.

Supervisor Signature:______Date:______

Title:______

To be completed by Department of Human Resources:

The above-named employee has been verified as a full-time employee and has met the eligibility requirements of the Growth Through Life program.

Hire Date: ______

Human Resources Representative: ______Date: ______

Human Resources Manager/Director: ______Date: ______

Tax Notice: There may be tax implications for this tuition benefit under IRS regulations. This benefit may be considered taxable wages and subject to income tax withholding. Employees should consult their own tax advisor for assistance and coordinate with Payroll to provide withholding or a standard withholding will be withheld.

Rev. 8/1/16

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