UTSA Employee Educational Benefit Program

Application Form

Please present this form to the Office of Student Financial Aid

Name ____________________________      Banner ID Number ___________________

Department _______________________       Work Phone Number __________________

Semester _________________________       Apply benefit for           ______ 3 credit hours 

______ 6 credit hours

______ Other (Specify)

• I am currently a benefits-eligible employee and have been such for at least 12 consecutive months

• I understand that I am responsible to pay all tuition and fees NOT listed below:

Tuition Designated Fund

Student Services Fee

Athletics Fee

Automated Services Charge

University Center Fee

Medical Services Fee

Publications Charge

International Education Fee

Recreation Center Fee

Library Resources Charge

Teaching & Learning Center Support Charge

ID Card Fee

• If I am found to be ineligible for this benefit, I will be responsible for reimbursing the exempted fees.

• I understand that the coursework does not have to be job related and that my supervisor’s approval is required if I want to take course work during my normal workday. (Refer to Handbook of Operating Procedures: Section 4.8 Employees as Students)

• I understand that I may use this benefit for a maximum of 6 credit hours per fiscal year.

• This form must be presented to the Office of Student Financial Aid for each semester the benefit will be used.

Signature: ____________________________________  Date: _____________________