Fillable Tuition Exchange Dependent Oct2013 (California Lutheran University)

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Tuition Exchange Dependent Oct2013 (California Lutheran University)

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Human Resources Department - 60 W Olsen Road #1100 - Thousand Oaks, CA 91360 - P: 805.493.3185 – F: 805.493.3655 Oct 2013
Application for Tuition Exchange & ELCA Scholarship
Dependent Child of Employee
Submit this form and Proof of Relationship*
Please complete entire form and return to the HR Department. Incomplete forms will not be accepted.
DEPENDENT STUDENT (CHILD) INFORMATION
LAST NAME
FIRST NAME
M.I.
PERMANENT HOME ADDRESS – STREET
CITY
STATE
ZIP CODE
CONTACT PHONE NUMBER
EMAIL ADDRESS
*Acceptable proof of relationship includes birth certificate and parental Tax Returns (must list the dependent as an exemption to qualify)
For additional reference please refer to the Employee Handbook.
APPLICATION INFORMATION
PLEASE INDICATE WHICH ACADEMIC YEAR AND BENEFIT THIS APPLICATION IS FOR
ACADEMIC YEAR:
NUMBER OF SCHOOLS APPLIED TO:
The Tuition Exchange (TE) Scholarship (tuitionexchange.org)
ELCA Tuition Exchange Scholarship (www.elca.org/Growing-In-Faith/Education/Colleges-and-Universities.aspx)
LIST INSTITUTIONS WHERE DEPENDENT IS APPLYING TO OR ATTENDING. (You may add to or delete from this list after the application is submitted).
NAME OF SCHOOL AND CITY/STATE
NAME OF SCHOOL AND CITY/STATE
PLEASE CONFIRM STATUS FOR ACADEMIC YEAR REQUESTED ABOVE:
ADMISSION STATUS:
APPLICATION SUBMITTED
ACCEPTED
CURRENTLY ATTENDING
FEDERAL PELL GRANT ELIGIBLE:
YES
NO
UNKNOWN
CLASS STANDING:
FRESHMAN (0-29 UNITS)
SOPHOMORE (30-59 UNITS)
JUNIOR (60-89 UNITS)
SENIOR (90-124 UNITS)
EMPLOYEE (PARENT) INFORMATION
LAST NAME
FIRST NAME
M.I.
EMAIL ADDRESS
DATE OF HIRE (MM/YYYY)
EMPLOYEE’S DEPARTMENT / WORK EXTENSION
POSITION TITLE
FACULTY
SALARY
ADMINISTRATIVE STAFF
SUPPORT STAFF
HOURLY
SIGNATURE
To the best of my knowledge, I certify that the above information is true and correct.
I have attached or have on file with Human Resources proof of relationship, including a copy of the Tax Return for parent of dependent child.
SIGNATURE OF DEPENDENT STUDENT (CHILD)
DATE
SIGNATURE OF EMPLOYEE (PARENT)
DATE
For HR office use only:
Eligible
Ineligible
FTE Status
Payroll Hours
ELCA only % of benefit
%
Tax Return Verified
HR Benefits Initials
AVP of Human Resources Signature
Date
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Tuition Exchange Dependent Oct2013 (California Lutheran University)

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Completed 20 July 2020

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