AAMU – Title III Strengthening Grants Program Form 4 – Updated 10-1-14
APPLICATION FOR SUPPORT TO PURSUE A TERMINAL DEGREE
Date: ________________
Name of Applicant: __________________________________ Check One: Faculty Administrative Staff
Faculty Rank: _________________________________ Administrative Position/Title: _________________________________________
Title: _______________________________________________ Highest Degree Held: __________________________________________
Check One: Full Time Educational Leave Assistance Part time Educational Leave Assistance
Office Number: _________________ Fax Number: _________________ E-mail Address: _______________________________________
Secondary Telephone Number: _________________ Home Address:
Number of Years Employed at the University: _____
Department Name: ______________________________________________ College: ___________________________________________
Check One: Program is accredited Program is seeking accreditation
Educational leave: from _______________________________ to _______________________________
Expected Beginning Date Expected Ending Date
Name and location of accredited graduate institution to be enrolled in while on educational leave:
(Please attach a letter of acceptance, planned degree program or requirements, name, telephone number, and e-mail address of major professor.)
Degree Pursuing: __________________________________________________ $___________________________
(Specify Ph.D., Ed.D., etc.) Amount of assistance requested
Justification for Request:
A letter of recommendation from supervisor must accompany this application.
If I accept the educational assistance, I agree to:
Enroll at the specified accredited institution during the period requested.
Submit to the department chair and Title III Office an official transcript of courses completed, grades and credits earned at the end of each
term.
Immediately upon graduation or discontinuing the graduate program, return to the University to render a minimum of six semesters(faculty)
three years (administrative staff) of full-time professional service. The annual salary will be paid in accordance with the prevailing salary scale.
Reimburse the University the full amount of support received if I fail to return to the University upon graduation or discontinuing the graduate
program.
_______________________________ __________
Employee Date
_______________________________ __________ _______________________________ __________
Signature of Supervisor or Dean/Chair Date Provost and V.P. for Academic Affairs Date
_______________________________ __________ __________
Title III Director Date
______________________________
President Date
Title III Action
Assistance Awarded Amount: _________________________ Date: ______________
Assistance Denied Reason for denial: _______________________________________________
_______________________________________________________________
