Employer Certification of Eligibility for Tuition Deferment Form

Employer Certification of Eligibility for Tuition Deferment Form





Firm Firm name:

Authorizing Individual:

Title:

Email address:

Address of Firm Street Address

City/Town

State   Zip

Student Name
Date Submitted:
  I certify that the above-named applicant is employed by our firm and is eligible for tuition benefits for:

Fall Semester
Spring Semester
Summer Semester
Required: Year
Total Benefit Amount: $
  Payment will be made directly to:

Bloomsburg University
Employee
Affidavit - I certify that all of the information provided by me is true, complete and correct. I understand the information provided in the form is subject to verification by Bloomsburg University. Note: This box must be checked to submit form.
Submit