TWU Local 100 - NYC Transit TRAINING & UPGRADING FUND

TUITION REIMBURSEMENT FORM

BASIC INFORMATION

Pass # *

Email *

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Job Title

Gender *

Male Female Other

Date of Hire *

PROGRAM INFORMATION

Type of College/University

Type of Course

Other Type of Course

Semester *

Start Date

End Date

Field of Study/Major/ Certification

Website

Name of Institituition

Address

Expected Graduation Date

Please describe how your course of study applies to your current or potential job responsibilities. *

OTHER FINANCIAL SUPPORT

I have NOT received any financial support, such as scholarships, fellowships, grants, veteran's benefits, etc, for the courses for which I seek reimbursement. I recognize that if such aid (which only is applicable to periods for which I have accepted TWU Local 100-NYCT Training and Upgrading Fund educational support) is received, I would be obligated to report such aid to the TWU Local 100-NYCT Training and Upgrading Fund and be required to repay an equivalent amount (up to the value of the applicable educational award).

I am receiving financial support, such as scholarships, fellowships, grants, veteran's benefits, etc, for the courses for which I seek reimbursement. I recognize that if such aid (which only is applicable to periods for which I have accepted TWU Local 100-NYCT Training and Upgrading Fund educational support) is received, I would be obligated to report such aid to the TWU Local 100-NYCT Training and Upgrading Fund and be required to repay an equivalent amount (up to the value of the applicable educational award).

Source Name	Amount Received ($)

COURSE INFORMATION

Course #	Course Name	Class Start Time	Class End Time	Days	Tuition $





				TOTAL Amount Requested:

CERTIFICATION

I certify that the information provided is accurate and true. And, except as reported above, I have not received any financial support, such as scholarships, fellowships, grants, veteran's benefits, etc, for the courses for which I seek reimbursement. I recognize that if such aid (which only is applicable to periods for which I have accepted TWU Local 100-NYCT Training and Upgrading Fund educational support) is received, I would be obligated to report such aid to the TWU Local 100-NYCT Training and Upgrading Fund and be required to repay an equivalent amount (up to the value of the applicable educational award). I understand that if the above course(s) is approved under the program, payment will initially be made at my personal expense. I understand that I will be entitled to reimbursement for applicable tuition and fees upon the submission of all necessary documents within the designated time frame. I permit the release of documents to TWU Local 100-NYCT Training and Upgrading Fund from relevant institutions to verify the accuracy of documents I submitted. The Tuition Reimbursement Program is offered at the discretion of TWU Local 100-NYCT Training and Upgrading Fund, which has the absolute right to modify or discontinue this Program in whole or in part. I understand that the receipt of a tuition reimbursement benefit for the 2018 / 2019 program year is not a guarantee, precedent, or promise from the Fund that it will make available tuition reimbursements in future years and, therefore, cannot be relied upon for that purpose.

I certify the above to be correct. *

I certify that I have read the TWU Local 100-NYCT Training and Upgrading Fund Tuition Reimbursement Program Manual in its entirety. (This document can be found on the web at www.TWUlocal100TUF.org). I understand that acceptance into this program is contingent upon my adherence to the stipulations set forth in this document. Falsified documentation will result in immediate termination from the Program, possible repayment of all funds received from the Program, and a possible ban from future participation in the Program.

I certify the above to be correct. *

Please Note: Upon submitting your application electronically, you should expect an automatic response indicating that we have received your application. Your application, however, is not considered complete until you submit all supporting documentation. Enrollment in the Program is on a first come first served basis for those submitting a complete application packet. The checklist below indicates those items that will be required as part of the full application for the Program.

*Members in OA Computer, Telecommunications and Other Non-Operating Titles are not eligible.*

Full Application Checklist:

Completed Application
Official Proof of enrollment in a Qualified Course
School Course or Program Description (Includes Start and End Date for Class)
Tuition and Other Fee Breakdown

Checklist for Submission of Application for Reimbursement

Use this Checklist to help you complete the Application for Reimbursement form and file for reimbursement of your eligible tuition expenses. On the reverse side is a Checklist that will help you determine if the course you are interested in is eligible for reimbursement under the Tuition Assistance Program.

Reimbursement Eligibility - To submit tuition expenses for reimbursement, you must meet (answer yes to) the following criteria:

Were you actively employed for a year on the first or last official day of class?
Are you submitting expense within 90 days of the first day of class for the semester?
Did you complete the course with a grade of C- or higher?
Have you paid your tuition expenses in full?

Transcript, including the following information:

School Name
Semester/course dates
Student name
Course title
Course grade

Proof of Tuition Payment, including the following information:

Itemization of fees (registration, tuition, technology, etc.)
School name
Student name
Date of transactions
Description of transactions
Amount of charges & credits
Method of payment (credit card, loans, cash, check, etc.)
Final balance of $0.00

Date

Signature*