EmailMe Form - Tuition Benefit Application

EmailMeForm

I am submitting a: *
New Application
Recertification
Faculty/Staff Information
Faculty/Staff Name Eligible for Benefit *
First Last
Faculty/Staff Title *
Wartburg ID# *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email *
Phone *
### - ### - ####
Hire Date *
MM / YY
Position *
Faculty
Administrative Staff
Support Staff
Pay Rate *
Hourly
Salaried
Please indicate whether or not the following statement is true:
Yes
No
The student named below is unmarried and my natural born/adopted/step child. I hereby certify that I will provide 50% of the student's support for the calendar year corresponding to the semester I am listing.
Student Information
Student Name *
First Last
Student Email *
Relationship to Employee *
Self
Dependent
Spouse
Student Date of Birth *
MM / DD / YYYY
Last 4 digits of Student's SSN *
Academic Year Applying For: *
Term(s) applying for
(check all that apply) *
Fall
Winter
May
Summer
Registration completed for the following courses (summer only):

Class Day(s)/Time

1.

2.

3.

4.

5.
Student's Academic Classification (for the academic year you are applying for): *
Freshman
Sophomore
Junior
Senior
Student Status *
Full-time
Part-time
Degree Options *
Degree Seeking
Non-Degree Seeking
Has this student obtained a bachelor's degree from Wartburg College or any other educational institution? *
Yes
No
How many previous semesters has the student received the Tuition Remission/Exchange benefit? *
Tuition Benefit Program
Tuition Benefit Programs (check all that apply) *
Tuition Remission (Attending WARTBURG COLLEGE)
ELCA (Indicate your choice(s) below)
Tuition Exchange (List college(s) below)
ELCA
Augsburg
Augustana (IL)
Augustana (SD)
Bethany
California Lutheran
Capital
Carthage
Concordia
Gettysburg
Grand View
Gustavus Adolphus
Lenoir-Rhyne
Luther
Midland
Muhlenberg
Newberry
Pacific Lutheran
Roanoke
St. Olaf
Susquehanna
Texas Lutheran
Thiel
Wagner
Wittenberg
**If you selected ELCA above, please check the box next to each school to which you are thinking of applying.
Tuition Exchange
**If you selected Tuition Exchange above, please list the school(s) to which you are thinking of applying. Please include the name of the school and the city/state it is located in.

Please note, if your application is approved by Wartburg, you will need to complete a separate application at TuitionExchange.org (new applicants only, not necessary for recertification).
Sign and Submit
I certify that all information listed above is accurate and all required forms will be completed on a timely basis. By signing below, I acknowledge that I have read the terms and conditions of the Tuition Benefit Programs.

Note: Students attending Wartburg as part of a tuition remission program are required to live on campus for a minimum of six terms.
Sign here *
Clear

	Class	Day(s)/Time
1.
2.
3.
4.
5.

Faculty/Staff Information

Student Information

Tuition Benefit Program

Sign and Submit