APPLICATION FOR TUITION REIMBURSEMENT PROGRAM
 
Click here to download the MLI Tuition Assistance Promissory Note
Employee Name*
 Job Title*
 Date of Hire*
School Name*
Soc. Sec. No.*
 
Have you been a permanent full-time active employee for at least one Semester?*
Yes No
     
IF THERE IS A QUESTION CONCERNING THIS APPLICATION I MAY BE REACHED AT:
Work Number*
 Home Telephone*
  
Grade/Subject Assignment*:
Home Address*

JSU Advisor*
School Phone*
REQUEST FOR COURSE APPROVAL
Academic Term Applying*: Fall Spring Summer
Course Date*
Course End Date*
Job Related*:
Yes No 		Is course part of a planned degree program?*
Yes No
Degree Sought*
 Classification*
 Anticipated Date of Graduation*:
Major*
 Reason for taking the course*
Course Code*
Course Title*
Tuition*
 Do you expect to receive GI Benefits, a Grant or Scholarship?*
If Yes, amount of aid*:
 
I understand that I must have a grade of “B” or better for all graduate courses or a grade of “C” or better for all undergraduate courses in order to be eligible for reimbursement up to $3,600 in tuition costs each fiscal year.

I understand that I must submit an official copy of my grades and a statement from the school stating how much I paid for the course (s) taken prior to the end of the fiscal year to be reimbursed.

I understand that if I voluntarily terminate employment in an MLA School, I will be required to reimburse MLI for all education assistance paid to me within the 6 months period following the date of employment termination.

I understand in accepting this continuous support from MLI, I am committing to service in an MLA School.

I understand these funds are applicable only to courses taken and completed at Jackson State University.

I understand this reimbursement is subject to the approval of my MLA principal and employer.
* Denotes required information.