Classified Staff Employee Book Scholarship Request

Employee Information

TMCC Staff Name:*

First NameLast Name

Employee ID:*

TMCC Email:*

example@tmcc.edu

Phone Number:*

Please enter a valid phone number.Format: 000-000-0000.

Department:*

Position/Title:*

Date Hired:

Hours Worked Per Week:*

Goals and Course Impact:*

Briefly summarize your educational goals and why the course related to your book scholarship application is important to you. Also, please state if you believe the course could assist you in getting an upgrade or promotion (do not include any sensitive personal information):

Course Information

NSHE Institution:*

FallSpring

Year:*

Name of Course:*

Course Prefix:*

Course Section:*

Call Number:*

Textbook Information

Name of Required Textbook:*

ISBN:*

Price:*

Certification and Acknowledgment

I understand that if I do not successfully complete the class, I will not be reimbursed for the cost of the book(s). A class is "not successfully completed" (as defined in State Administrative Manual 284.490) if the student:

1) Drops the class;
2) Quits attending;
3) Terminates employment at TMCC;
4) Receives an incomplete; OR
5) Does not receive a grade of 'C' or better.

By pressing submit, I agree to the terms of this contract and am verifying that all of the information provided above is true, correct, and complete.

Please verify that you are human:*

Sender Name: