Staff Council Tuition Scholarship Application

Return to Colleen A. Martin, 606 Jefferson Building

 

Name (print):___________________________________________________________________

Department:___________________________________________________________________

Campus Address: _______________________________________________________________

Phone:_______________________Beginning date of employment at UI (month/date/year)_____________

Email address:__________________________________________________________________________

Social Security Number:_________________________ Job Title:____________________________

(List only one course—may be up to 5 credit hours)

Department/Course/Section Number: ________________________Number of Credit Hours ___________

Title of Course:__________________________________________________________________

 

This course is offered by:  ____ UI undergraduate college  ____ MBA Tippie School of Management
____ Graduate College  ____ Guided Correspondence Study
____ Saturday & Evening Courses ____ Evening MBA Program
____ Guided Independent Study

____   Other (please specify)__________________

 Total Cost of Tuition for Course (excluding any fees): $_______________________________

 

I will be registering as an/a    ____ undergraduate ____ graduate ____ special student

 

Circle Session for Application:              Summer                  Fall                       Spring
 

I have read and agree to the above terms of the Staff Council Tuition Scholarship Program.

 

Signature:________________________________________________________________Date:_____________________