PRE-PAID TUITION APPLICATION
Participant Information
Application Type
Please Choose
1: Pre Paid Tuition
2: Tuition Reimbursement
First Name
Last Name
HRID
Home Street
Home City
Home State
Home Zip
Day Time Tel
ex: 2125551212
Email
Confirm Email
Employment Information
Employer
Please Choose
1: AT&T
2: Alcatel-Lucent
3: Avaya Inc.
Seniority Date
(mm/dd/yyyy)
Employment Status
Please Choose
1: Active
2: Laid Off
Lay Off Date
(mm/dd/yyyy)
School Type
Please Choose
1: For Credit Training at an Accredited School
2: IT/Technical Certification
3: Industry Standard Certification/Licensure at an Alliance Approved School
Program Type
Please Choose
1: For Credit Training
2: Certification
3: Licensure
School Address
School Name
Street
City
State
Zip
Contact
Phone
ex: 2125551212
Program Information
Program Title/Major
Term Begin Date
(mm/dd/yyyy)
Term End Date
(mm/dd/yyyy)
Course 1
Course No.
Course Title
Number Credits
Class Hours
Tuition Cost $
Course 2
Course No.
Course Title
Number Credits
Class Hours
Tuition Cost $
Course 3
Course No.
Course Title
Number Credits
Class Hours
Tuition Cost $
Course 4
Course No.
Course Title
Number Credits
Class Hours
Tuition Cost $
Total Cost $
Conditions
I understand that I am responsible for the payment of all non-approved costs and fees and
I agree to provide required information for the administration of The Alliance Pre-Paid Tuition
program. I authorize any education institution that I attend to release any requested information
pertinent to this program regarding my status in the institution, including the release of a
transcript or other information as outlined in this program to The Alliance Pre-Paid Tuition
Program.