Public Health Leaders of Tomorrow

Initial Application for Tuition Award

PHLOT tuition awards areavailable to NYS Local Health Department or NYS DOH employees who are currently enrolled in the MPH, DrPH or Certificate program/s at the UAlbany School of Public Health (must be US citizens or permanent residents).

Please notepreference is given to LHD employees seeking first graduate degree

in public health (including certificate programs).

Name: ______Date: ______

Email Address: ______Phone/s: ______

Mailing Address: ______

Apartment & Building Number, Street or Post Office Box

______

CityState Zip Code (Country if not US)

*Please inform us immediately if any contact information changes. Thank you.

Employer: ______Your Position ______

*Please note: We require documentation of full-time employment status AND any available assistance available first through your employer/union.

Supervisor’s Name:______Contact Information: ______

US Citizen Permanent Resident

Currently Enrolled in Which Degree/Certificate Program:

Certificate in Public Health Fundamentals & Principles

Certificate in Public Health Surveillance & Preparedness

MPH DrPH

Student ID Number

Please indicate course/s in which plan to enroll:

1. ______Number of Credits: ______2. ______Number of Credits: ______

Please Note:

  • All full-time NYS DOH and LHD professionals are required to first utilize any tuition assistance available through their employer/union. Please attach supporting documentation.
  • PHLOT coversTUITION ONLY. All other fees (student fees, late fees, etc.) are the responsibility of the student.
  • Students who withdraw from courses will be responsible for the cost of tuition.

Please submit completed form to Maggie Watson, Assistant Director
Public Health Leaders of Tomorrow Program

University at AlbanySchool of Public Health – One University Place

Rensselaer, NY12144

518.402.0404

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION

(Required by Public Officers Law, Section 94.1 (d))

The principal purpose for requesting this information is identification, merit employment systems management, payment, fiscal and demographic reporting. Failure to provide any or all of the requested information may affect your eligibility, compensation, and/or employment status. Information maintenance is permitted by NYS Civil Service, Fiscal, Retirement and Labor Laws & Rules; federal Social Security Law; NYS & federal Affirmative Action/EEO Laws & Rules; and NYS Executive Orders. The information will be maintained in the office of the Director of the Preventive Medicine Residency Program, NYSDOH/SPH, Room 1882, CorningTowerBuilding, EmpireStatePlaza, Albany, New York12237-0621, telephone number (518) 474-1911. Each individual has the right to review personal information maintained by the agency, unless exempted by law.

Revised 10/23/2018