Student Business Services
863-874-8406 Room 1101A
4700 Research Way
Lakeland, Florida 33805-8531
SBS@floridapoly.edu
Deferred Corporate Tuition Assistance Program
Enrollment Agreement Application
Student Information
First Name: Last Name:
Phone Number: Email:
Street Address:
City: State: Zip Code
Student ID: Calendar Year
Book Voucher: Job Title:
Employment Status
Full-time Part-time
Employer Information
I confirm that is eligible for reimbursement from
Employer Name: Title:
Phone: Email:
Employer Signature: Date:
Student Disclaimer and Signature
Students who are eligible for tuition reimbursement are responsible for any balance incurred,
regardless of employment status, changes in eligibility, or reimbursement status, within 30 days from
the end of the term. Students participating in the plan have the option to use a book voucher in
advance to purchase textbooks and course materials, if the employer covers the costs of books up to
$1,000 per semester.
By signing this form, I certify that I am authorized by the employer to sign for this benefit.
Student Signature Date
Employer Signature Date
click to sign
signature
click to edit
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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