______   Semester  ______ Year        Tuition ______ or Portfolio Reimbursement  ______

PERSONAL INFORMATION 

NAME  _____________________________________  WV Resident _____  Out-of-State Resident _____

WVU ID #____700 - ________________________     E-Mail  ______________________________________

HOME ADDRESS  _________________________________________________________________________

Home Phone #  ______________ Birth Date __________ Hours Worked Per Week  ___________________

Campus Department ______________________   P O BOX  ___________   Work Phone #  ____________

EDUCATIONAL INFORMATION 

DO YOU CURRENTLY ATTEND A COLLEGE OR UNIVERSITY?     Yes  _____    No  _____

IF NO, HAVE YOU MADE APPLICATION TO A COLLEGE OR UNIVERSITY?   Yes _____   No _____ 

If yes, what institution do you attend? ___________________________________________________________

If no, what institution do you plan to attend? ______________________________________________________

What program or major? ______________________________ 

Current Grade Point Average ______________ (Refer to #8 in eligibility requirements.) 

Do you have a college degree?     Yes _____   No _____

If yes, circle all that apply:    Associate            Bachelor       Masters      Ph.D.   

                                             Note:  Degree information will be verified!!   

                                                                                   CERTIFICATION      

I certify that the above statements are true and I authorize  Staff Council’s Tuition Assistance Committee to make inquiries it deems necessary with this application.  I understand this assistance is for obtaining the first UNDERGRADUATE DEGREE and confirms that I am not seeking assistance for credits toward a second undergraduate degree or graduate degree and that I am not a graduate student.

Applicant’s Signature                                                                                              Date 

Endorsement of this request by the Supervisor, Dean or Director is required if the course is to be taken during the employee’s regular working hours.  Employees must adhere to the guidelines established by WVU policy on Educational Release Time.  Please indicate N/A on the signature line if this section is not applicable to your class time.  

Endorser’s Signature                                                                                              Date

PLEASE NOTE THE FOLLOWING ELIGIBILITY REQUIREMENTS AND ALSO NOTE THAT YOU CAN ONLY APPLY TWO SEMESTERS DURING AN ACADEMIC YEAR.

Last update: December 13, 2006