Employer Agreement to Pay Tuition Form

Legal First Name

Legal Last Name

Student ID Number:

Program

Current Concentration(s)
Hold down the CTRL or Command key to select more than one.

I am enrolled in multiple programs

Yes

No

Current Concentration(s)
Hold down the CTRL or Command key to select more than one.

Academic School Year

For the this academic year, I have employer benefits that will cover all or part of my charges for attending Whitworth University.

Whitworth employees should complete the Tuition Remission Form instead.

Employer Information:

Employer Name:

Address:

Benefits Contact Name:

Contact Phone:

Contact Email:

Employer Financial Support:

Summer 1 (May - Aug of starting year)

Percent Covered

Amount

Fall (Aug/Sept - Dec)

Percent Covered

Amount

Spring (Jan/Feb - May)

Percent Covered

Amount

Summer 2 (May - Aug of ending year)

Percent Covered

Amount

Process to receive Employer Funds:

If you do not know your employer’s requirements to receive funding, please confirm before completing this form.

I understand that I am responsible for processing all necessary and required documents to receive educational funding from my employer. To receive the funds I must (select all that apply):

Submit a transcript that shows the completion and grade for the course(s)

Provide an invoice of the charges for the course(s)

Provide a copy of my student account statement that shows the charges for the course(s)

Submit a receipt showing that I paid the course charges myself

Other

Statement of Understanding/Promise to Pay:

I understand that Whitworth University will charge my student account for tuition and any applicable fees related to my attendance and, as a courtesy the university is allowing me to defer payment to the end of the term on the bases of my employee benefits. I acknowledge that as any other student I am responsible for all balances in my account including those not paid by my employer for any reason within 30 days of the term’s conclusion. If the account is not paid in full within 30 days of the end of the term, a late charge will be applied and the account may be remitted to a collection agency.

Student's Signature (print legal name)

Date