Service And Trade Unions Form
ADVERTISEMENT
1
2Service and Trade Unions Form
Tuition Assistance Plan
HARVARD UNIVERSITY
Non-Harvard Course Reimbursement
Benefits
For License or Certificate programs
See Back for Guidelines
□□□□□□□□
Harvard ID #:
Department: ___________________________
Name: First __________________________ MI _______ Last __________________________________
Home Address: __________________________________ Daytime Phone: (______)_________________
City: _____________________________ State: ________ Zip Code: _____________________________
Date of Hire/Appointment: __________________________ Years of Service: _______________________
□
Employment Status:
Hourly
□
□
Union Affiliation:
Carpenters (Local 51)
Electrical Workers (Local 103)
□
□
□
Food Services (Local 26/SWU/other)
HUPA
HUSPMGU
□
□
□
Operating Engineers (Local 877)
Plumbers (Local 12)
SEIU
I hereby certify that 1) I meet the eligibility requirements as stated on reverse side, and 2) will not
be covered by any other employer plan or any other person. My employer does not accept
responsibility for direct payment to any individuals other than the employee. I have read and
understand the information on this form.
_____________________________________________________ _______________________
Signature of Staff Member
Date
_____________________________________________________ _______________________
Signature of Supervisor (required prior to the start of the course)
Date
_____________________________________________________ _______________________
Signature of Personnel Officer
Date
□
□
□
□
1. Semester:
Fall
Spring
Summer
Full Year Course
□
□
2. Type of Credit:
License
Certificate
3. School/Program offering the course: _____________________________________________
4. Course Number: _____________________________________ Credit Hours: ____________
(if applicable)
Course Title: ________________________________________________________________
Course Start Date: _______________ Course End Date: _______________
□
5. Why this course is needed:
Requested by Supervisor
□
Upgrade skills/knowledge necessary for current job
□
Upgrade skills/knowledge necessary for another job at the University
□
Type of License or Certificate:_______________________________
(HVAC, electrical, plumbing, cooking, horticulture, etc)
6. Total Course Cost: $___________________ (tuition only)
7. Grade: _________ (to be supplied to Crosby Benefit Systems within 60 days after the end of
the course)
Mail to Crosby Benefit Systems, 27 Christina St, Newton, MA 02461
or Fax to 617 928 0001
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business