EMPLOYEE SCHOLARSHIP PROGRAM FORM

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

EMPLOYEE SCHOLARSHIP PROGRAM - REQUEST FORM

Name*

First Name

Last Name

Date*

Department*

Title*

Email*

Supervisor's Email*

Section 1

Please indicate the external training opportunity (course, seminar, workshop, licensure, certification, etc.), date, and approximate program cost that you are interested in pursuing through the Employee Scholarship Program (attach additional sheets if necessary):

Name of Program*

Date/Time*

Approximate Cost:* $

Please indicate how the program listed above will either enhance your current skill level/effectiveness or broaden your knowledge/skills for future job assignments and promotional opportunities:*

Additional Documents (Optional)

No File Chosen

File uploads may not work on some mobile devices.

Section 2

Educational assistance benefits under this plan are reviewed and approved by the Director of Employee Relations. The current maximum amount for this plan is $2,500.

1. Is the course required to meet the minimum education requirements of your position?*

Yes No

2. Is the course part of a program of study that will qualify you for a new trade or business?*

Yes No

3. Will the course help you maintain or improve skills in your current position?*

Yes No

4. Is the course required as a condition to retain your current position or pay rate?*

Yes No

For the course to possibly qualify as a tax exempt Working Condition Fringe, the answers to the first two questions must be “No”, and the answer to either the third or fourth question must be “Yes”. Financial Services will use this information to help determine taxability.

By signing below, I certify that I have answered the above questions accurately. I understand that if the training opportunity is found not to be job-related, I may have to pay taxes on the value of the course. If the value of the training opportunity is taxable, I also understand that I may owe income tax, FICA payments, and/or penalties and interest, and I agree to assume responsibility for paying these amounts.

Signature*

[clear]

Date/Time*

SUPERVISOR APPROVAL

To the Supervisor: Please answer the following questions to indicate whether the above course is job-related.

1. Is the course required to meet the minimum education requirements of the employee’s*

Yes No

2. Is the course part of a program of study that will qualify the employee for a new trade or business?*

Yes No

3. Will the course help the employee maintain or improve skills in his/her current position?*

Yes No

4. Is the course required as a condition for the employee to retain his/her current position or pay rate?*

Yes No

By signing below, I certify that I have answered the above questions accurately and that I approve of this employee pursuing the indicated training opportunity.

Name*

First Name

Last Name

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*

Phone Extension*

HR REVIEW

Request is:

Approved Partially Approved Denied

Value of Benefit $

Comments

HR Approval Signature

[clear]

Use your mouse or finger to draw your signature above

Signature Date