Pre-Paid Tuition Application


Participant Information

Application Type: (required)

First Name (required)

Last Name (required)

ATTUID/HRID (required)

Home Street (required)

Home City (required)

Home State (required)

Home ZIP (required)

Day Time Tel (required), please use this format: 000-000-0000

Email (required)

Confirm Email (required)

Employment Information

Employer (required)

Seniority Date (required), please use this format: YYYY-MM-DD

Employment Status (required)

Lay Off Date, please use this format: YYYY-MM-DD

School Information

School Type (required)

Program Type (required)

School Name (required)

Street (required)

City (required)

State (required)

ZIP (required)

Contact (required)

Phone (required), please use this format: 000-000-0000

Program Information

Program Title/Major. (required)

Term Begin Date(required), please use this format: YYYY-MM-DD

Term End Date(required), please use this format: YYYY-MM-DD

Course 1

Course No. (required)

Course Title (required)

Number of Credits (required)

Class Hours (required)

$Tuition Cost (required)

Course 2

Course No.

Course Title

Number of Credits

Class Hours

$Tuition Cost

Course 3

Course No.

Course Title

Number of Credits

Class Hours

$ Tuition Cost

Course 4

Course No.

Course Title

Number of Credits

Class Hours

$ Tuition Cost

TOTAL TUITION

$ Total Tuition 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 and documentation required by 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 and other information as outlined in this program to The Alliance Pre-Paid Tuition Program. All information I supplied is accurate to the best of my knowledge and I have not willingly misrepresented any information contained herein.