EMPLOYEE INFORMATION             Date of Birth / /                                                            UPS EARN AND LEARN PROGRAM

Employee ID

Home Telephone
( ) -

Work Telephone
( ) -

Date of Employment
       Date:  / /

Last Name

First Name

M.I.

Position/Title

Street Address

City

State

Zip Code
-

Degree/Major

School Name

Term Begin          / /

Street Address

Term End             / /

City

State

Zip Code

Anticipated Graduation Date   / /

School Telephone

Course No.

Course Description

Credits
.

Estimated Tuition
$ .

Estimated Total
$ .

.

$ .

$ .

.

$ .

$ .

.

$ .

$ .

     Mandatory Fees           $ .
Total Estimated Cost         $ .

                                      Source   (Subtract from total)                        Amount                      $ .
                                                                                                                 Net Amount Requested                          $ .

As a part-time employee, I wish to enroll in the above course(s) under the Education Assistance Earn and Learn Program.  I certify that the information above is true and accurate.  I understand that approval of my participation and my selected course(s) rests with UPS, and that such approval does not guarantee employment or advancement with the company.  My participation is voluntary, not considered hours of work or employment, and is not subject to compensation.  In addition, I understand that within 60 calendar days of completing the course(s), I must submit the appropriate documentation for payment, unless my school offers a direct billing arrangement:  1) an itemized invoice or fee statement from the school that clearly separates tuition, fees and books; 2) proof of payment and/or itemized receipts; 3) a grade report indicating that I have satisfactorily completed the course(s).  I understand that I must still be employed by UPS at the time documents are submitted for reimbursement.  I also authorize the above institution to release to UPS all records, including grades, or information on my education or financial assistance as it pertains to this application.  

TAX REGULATIONS

Depending on the status of federal tax laws at the time payments are made, UPS may treat education assistance benefits as taxable income to you.

STUDENT

Fax completed form to:  215-968-8349
E-Mail:  grahamj@bucks.edu