1. Please tell us about yourself:

    Name:    Plant/Department:

    Address:

    City:     State: Zip:

    Home Phone:    Work Phone:

    Date of birth:    USWA Local No.:

    Social Security Number:    Badge Number:

 2. Please tell us about the school you plan to attend:

    School Name:    Department:

    Address:

    City:     State: Zip:

 3. Please tell us about your study plans:

    High school completion/GED                                Bachelor degree

    Certificate                                                            Graduate Degree

    Associate degree                                                  Other:

    Continuing Education

    Describe each course covered by this tuition request:

    Course name:                                                           Course number:       Credit hours:

    Term starts on:                     Term ends on:

  4. I agree that:

    a. This request covers tuition, mandated books and course related fees.
    b. This request does not include tuition assistance from any other source.
    c. I will attend classes on my own time.
    d. When I finish my studies, I will send proof of completion, such as grade report, to
        Career Development Program.
    e. I hereby authorize the above named school to release the above information.

  5. Please tell us about your tuition:

    Total tuition:                           

    Other tuition assistance:           

    Total assistance requested: