TO BE COMPLETED BY EMPLOYER Sample Clauses

TO BE COMPLETED BY EMPLOYER. I certify that the below named applicant is employed by our company, and is eligible for tuition benefits in the amount of $ for the Summer 2019 term. Name of Certifying Official Signature of Certifying Official Company Name Title of Certifying Official Phone Number of Certifying Official Date

TO BE COMPLETED BY EMPLOYER. Please complete the following to verify that the above named student is eligible for tuition reimbursement. The employer will not be held liable by Xxxxxx University for any charges incurred by the student. Company Name: _____________________________________ Phone #: _____________________ Authorized Official: __________________________________________________________________ Employer Signature ____________________________________ Date________________________ Return to: Xxxxxx University Bursar’s Office 00 X. Xxxxx Xxxxxx Xxxxxx-Xxxxx, PA 18766 Email: xxxxxxx@xxxxxx.xxx

TO BE COMPLETED BY EMPLOYER. I CERTIFY that the statements above concerning service of the above named NFLP loan recipient as a full- time nurse faculty are true and correct. Name of Certifying Official Title Phone Number: Fax Number Signature: Date If the above named participant has not maintained faculty status during this period, please provide the date(s) and explanation for the change. Date(s): Explanation: WARNING: ANY PERSON WHO KNOWLINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION OF THIS FORM IS

TO BE COMPLETED BY EMPLOYER. This document acknowledges that this student is eligible to receive tuition assistance to cover educational expenses for the noted academic year. Company name and address: Name of company official: Phone number: Expected benefit amount per academic year: $ The company will send payment: Prior to semester End of semester (pending grades) Signature of company official: Date: ** Note: Please attach a copy of your company’s tuition assistance policy. ** Return the completed form and documentation to: Hamline University, Student Accounts Office, MS-A1770, 0000 Xxxxxx Xxxxxx, St. Xxxx, MN 55104, or fax to 000-000-0000, or email xxxxxxxxxxxxxxx@xxxxxxx.xxx. Questions? Contact Student Accounts at 000-000-0000. Internal Use Only: EP Coded: EMPLR Entered: FA Checked:

TO BE COMPLETED BY EMPLOYER. I , understand that, , is currently supervised by Xxxxx County Community Corrections and that he / she must comply with the General Rules and Special Conditions of Supervision. Signature: (Position / Title) (Date) Company Name: Address: City: State: Zip: Phone: Direct Supervisor: After Hours Phone: Other Work Station: Start Date: Part-time: Full-time: Number of hours / week: Hourly Wage: To be completed by employee: I _, a participant under the supervision of Xxxxx County Community Corrections and employee of the above named company or organization agree to permit my employer to share all of my employment information with Xxxxx County Community Corrections. This permission remains in effect until the end of my supervision by Xxxxx County Community Corrections or the end of my employment, whichever occurs first. I further agree to comply with the rules as outlined in this document, the rules of the Xxxxx County Community Corrections program, and the policies and rules set forth by the employer. By my signature I, , , hereby consent Name (Print) Date of Birth to communication between Xxxxx County Community Corrections and the above named employer. The purpose of, and need for, this disclosure here in is for case management purposes. I give ACCC and the above employer authorization to exchange all relevant information including drug and alcohol testing results / information. I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Record, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance thereon, and that in any event this consent expires automatically on my release date from Xxxxx County Community Corrections or my last date of employment with the above listed employer. Printed Name: Signature: Date:

TO BE COMPLETED BY EMPLOYER. This document acknowledges that this student is eligible to receive tuition assistance to cover educational expenses for the noted academic year. Company name and address: Expected benefit amount per term: Summer $ Fall $ Spring $ The company will send payment: Prior to semester End of semester (pending grades) Signature of company official: Date: Name of company official: Phone number: ** Note: Please attach a copy of your company’s tuition assistance policy. ** Return the completed form and documentation by mail to: