Family Tuition Policy: Centennial College — Application Form

Family Tuition Benefit Application Form

Reset Form
This application
applicationform
formmust
mustbebecompleted
completed byby
both thethe
both registered student
registered and and
student the Centennial College
the Centennial employee.
College It must
employee. It be
must submitted by the by
be submitted college employee
the college
to the Human
employee Resources
to the Office no later
Human Resources than
Office nothe deadline
later to "withdraw
than the deadline without academic
to ‘withdraw penalty"
without for thepenalty’
academic given semester. (An application
for the given semester. must be submitted
(An application
on
musta per-semester
be submittedbasis.) NOTE: This information
on a per-semester basis.) NOTE:is collected under the
This information Legal Authority
is collected under theofLegal
the Colleges
Authority and Universities
of the Colleges and Act, R.S.O. 1980,
Universities c272, 1980,
Act, R.S.O. s.5:R.R.O.
1980, s.5:R.R.O.
c272, reg. 640, 1980,
and isreg.
used byand
640, the isCollege
used byfor
theadministering the College's
College for administering theFamily Tuition
College’s Benefit
Family TuitionPolicy
Policyfor
Benefit
partial
Policy
for tuition
for tuition
partial fees
fees rebate.
partial tuitionrebate. Anyinquiries
fees rebate.
Any inquries about this
Any inquiries
about
authorization may
aboutauthorization
this be directed
thuis authorization
may bemay to the
be directed
directed Benefits
to theto Consultant,
Benefits Consultant,
the Benefits
Director, Human Human
Human
Consultant,
Resources,
Resources,
Human
Resources, Centennial
Centennial
Resources,
Centennial College.
College.
Centennial
College. College.

A B O UT THE REGISTERED S T U D E NT (This section must be completed by the registered student.)

NAME: _________________________________________________________________________________________________________________
Last/Family Name First/Given Name Middle Name

STUDENT NO: ____________________________________________________________________________________________________________

NAME OF PROGRAM: ______________________________________________________________________________________________________

CAMPUS: _______________________________________________ SEMESTER OF REGISTRATION (e.g.Fall 2013

Fall 20XX
2001) __________________________

I certify that the above information is true and complete. For the purpose of administering the Family Tuition Policy, I authorize Centennial College to share my
registration status with the college employee named in this application.

Signature of Student ______________________________________________________ Date ___________________________________________

A B O UT THE FULL-TIME COLLEGE E M P LOY E E (This section

(This section must
must be completed
be completed by the
by the college college employee.)
employee.)
empoyee.)

NAME: _________________________________________________________________________________________________________________
Last/Family Name First/Given Name Middle Name

EMPLOYEE NUMBER:
SOCIAL INSURANCE NUMBER: ____________________________________ SEMESTER FOR BENEFIT (e.g.Fall
Fall20XX
2013
2001) __________________________

DEPARTMENT/SCHOOL: ____________________________________________________________________________________________________

CAMPUS: _______________________________________________________________ COLLEGE EXTENSION NO.: __________________________

REGISTERED STUDENT’S RELATIONSHIP TO YOU: _________________________________________________________________________________

II certify
certify that
that the
the above employeeinformation
above employee information is is true
true and
and complete.
complete. My Mysignature indicates
signature indicates that that I consent
I consent to verification
to verification of theofinformation
the information provided
provided by waybyof way of
reference
reference totomymycollege
college employee
employee record.
record. My signature
My signature also indicates
also indicates I contractually
I contractually agree
agree to to be governed
be governed by the
by the rules andrules and regulations
regulations of Centennial
of Centennial College’s Family
College's Family
Tuition Policy, and Tuition Benefit
that I am awarepolicy, andisthat
the Policy I am aware
available on thethe PolicyIntranet
College’s is available on the
or from the Human
College's Intranet
Resources or from the Human Resources Office.
Office.

Signature of Employee ____________________________________________________ Date ___________________________________________

O FFICE USE ONLY ( Semester:__________________)

Registrar’s Office: Human Resources Office Accounts Receivable Office Payroll Office
▼ ▼ ▼ ▼
Student’sStudent's
status forstatus for the semester:
the semester: Is Is
College
CollegeEmployee
EmployeeEligible forfor
Eligible Note Dollar
Note Dollar Benefit
Benefitfor
forthe
theSemester:
Date Benefit paid:
(After
(After the semeste's
semester’s deadline deadline
the semester's deadlineto
to to Benefit?
Benefit? Semester:
withdrawwithdraw without academic
without academic penalty.) penalty)

■ FT ■ FTPT ■ PTWithdrawn
Withdrawn ■ YES
YES ■ NONO ■ FT FT $ _________________
$ __________________
Student meets benefit
Student meets benefit
requirements? (If no, list reasons and attach to PT $ __________________
requirements? this
(If form)
no, list reasons and attach to
■ YES ■ NO this form) ■ PT $ _________________ Payroll Office Signature
YES and NO
If no, list reasons attach to Date Benefit Paid: ____________________
If no, list reasons and attach to
this form.
this form.
Date
Human Resources Office Accounts Receivable Office
___________________________ ___________________________ ______________________________
Signature
Registrar’s OfficeOffice
Registrar's Signature
Signature Signature
Registrar's Office SIgnature Human Resource Office Accounts Receivable Office
Signature Signature

___________________________ ___________________________ ______________________________

Date Date Date
Date Date Date