x0000x0000January 2019WODU 26PLEASE PRINT ALL INFORMATION 150 - PDF document

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n n ��January 2019WODU 26PLEASE PRINT ALL INFORMATION – DO NOT USE ABBREVIATIONSApplicant InformationDate you began State Service NYS EMPLID Number (found on paycheck stub)(Required for payment by the OSC) N __ __ __ __ __ __ __ __ First and Last Name (as it appears on your NYS paycheck stub)Job Title Home AddressAgency Name CityStateZIP codeFacility/Department/Division Name Home PhoneCell PhoneWork PhoneExtension Primary Email Address Current Job StatusFull Time Part Time (50% or more) Less than half time ourse Details Name of Accredited Educational Institution Are you matriculated in a degree program?Yes If matriculated, what is your major? Course NameStart Date (mm/dd/yyyy)End Date (mm/dd/yyyy) Course NumberNumber of course creditsCourse grade ourse TypeUndergraduate Graduate Post Graduate Certificate Program Specialized Certification Is this course or event related to your current job or your career progression with NYS?JobCareer If career related, explaincareer ladder or career change Tuition costof the course, not including any Other assistanceyou have received or will be receiving from your agency, facility, or feesfrom other sources (not including this request) $ $ Nurses’ Enhanced (Must be a PEFrepresented nurse matriculated in a Nursing Degree Program)I have read page 8 of the CTR Guidelines and recognize there are different ways to utilize these benefits. I request to use them as indicated below and understand that this decision cannot be altered once the application is approved. (Choose only one)The remaining cost of a course that exceeded the maximum of a standard CTR benefit. I understand that by using any portion of each benefit, I will be exhausting that benefit in its entirety. The cost of an additional course Certification OSCwillithholdtimatedaxeshe end ofcalendarromployeesbenefitsfromhisogramadditionalducationalefitsromheirncyceed $5,250.hisesultubstantialithholdifromchecksd applicantshoulplancordingly.nderstandhatncurliability.(required)Byigning and dating thisapplication,ertifyhatinformaticontained on thispplicatiattached supporting documentation isrue and accurate.understand the guidelineshisprogramagree to complyith all Use digital signature or print application and hand sign. SignatureDate COLLEGE TUITION REIMBURSEMENT PROGRAM APPLICATIONANDNURSES’ ENHANCED COLLEGE TUITION REIMBURSEMENT PROGRAM APPLICATION ��January 2019WODU 26his application form can be used to apply for reimbursement through the College Tuition Reimbursement (CTR) and Nurses’ Enhanced CTR Programs. A separate application must be submitted for each successfully completed course. The CTR Program will not cover incomplete or failed courses or CBEs. Complete program guidelines can be found at www.goer.ny.gov/publicemployeesfederationaflciopefApplications andsupportingdocumentation must be submitted within 90 calendar days after the end date of the course. All supporting documentationmust have the applicant’s name printed on by the issuing entity. Documentationsubmitted by emailmust be in PDF format. All other formats (JPGs or other photo formats, Word Documents, links to documentationor websites, etc.) will not be accepted. The documents in the following checklist are required: Unaltered invoice, receipt, or itemized summary from the school, clearly showing the cost oftuition (separate from any additional fees)roof of payment, such as a valid receipt of payment from the school, loan agreement, bankstatement, credit card statement, or cancelled checkDocumentation showing any financial assistancethat has been or will bereceived toward thecost of the course indic

2 ating the name of the entity providing t
ating the name of the entity providing the assistanceDocumentation confirming matriculation status (if applicable) and course typeDocumentation showing the start and end dates of the course (month, day, and year)Documentation from the provider showing your passinggrade. An “official transcript” is notrequired.ubmit signed, dated application, and supporting documentation in one of the following ways: Email: Emailapplication and supporting documentationby the application deadline topsttraining@goer.ny.gov. All emailed documentation must be in PDF format. All other formats(JPGs or other photo formats, Word Documents,links to documentationwebsites, etc. willnot be accepted.)U.S. Mail: Mail application and supporting documentation, postmarked by applicationdeadline to:NYS Governor’s Office of Employee Relations PSTP Reimbursement Unit, 7th Floor 2 Empire State Plaza Albany, NY 122231250 Submitting duplicate applications may cause a delay in processing reimbursement. GOER is not responsible for lost, misdirected, late, or incomplete applications. All questions can be addressed to psttraining@goer.ny.govor by calling (518) 4746612. COLLEGE TUITION REIMBURSEMENT PROGRAM APPLICATIONNURSES’ ENHANCED COLLEGE TUITION REIMBURSEMENT PROGRAM APPLICATION ��January 2019WODU 26PLEASE PRINT ALL INFORMATION – DO NOT USE ABBREVIATIONSApplicant InformationDate you began State Service NYS EMPLID Number (found on paycheck stub)(Required for payment by the OSC) N __ __ __ __ __ __ __ __ First and Last Name (as it appears on your NYS paycheck stub)Job Title Home AddressAgency Name CityStateZIP codeFacility/Department/Division Name Home PhoneCell PhoneWork PhoneExtension Primary Email Address Current Job StatusFull Time Part Time (50% or more) Less than half time Course Details Name of Accredited Educational Institution Are you matriculated in a degree program?Yes If matriculated, what is your major? Course NameStart Date (mm/dd/yyyy)End Date (mm/dd/yyyy) Course NumberNumber of course creditsCourse grade ourse TypeUndergraduate Graduate Post Graduate Certificate Program Specialized Certification Is this course or event related to your current job or your career progression with NYS?JobCareer If career related, explaincareer ladder or career change Tuition costof the course, not including any Other assistanceyou have received or will be receiving from your agency, facility, or feesfrom other sources (not including this request) $ Nurses’ Enhanced (Must be a PEFrepresented nurse matriculated in a Nursing Degree Program)I have read page 8 of the CTR Guidelines and recognize there are different ways to utilize these benefits. I request to use them as indicated below and understand that this decision cannot be altered once the application is approved. (Choose only one)The remaining cost of a course that exceeded the maximum of a standard CTR benefit. I understand that by using any portion of each benefit, I will be exhausting that benefit in its entirety. The cost of an additional course Certification OSCwillithholdtimatedaxeshe end ofcalendarromployeesbenefitsfromhisogramtionalducationalefitsromheirncyeed $5,250.hisesultubstantialithholdifromchecksplicantshoulplancordingly.nderstandhatncurliability.(required)Byigning and dating thisapplication,tifyhatinformaticontained on thisicatiattached supporting documentation isrue and accurate.understand the guidelineshisprogramagree to complyith allcomply Use digital signature or print application and hand sign. SignatureDate COLLEGE TUITION REIMBURSEMENT PROGRAM APPLICATIONANDNURSES’ ENHANCED COLLEGE TUITION REIMBURSEMENT PROGRAM APPLICATION