Employer Certification of Eligibility for Tuition Deferment You must have JavaScript enabled to use this form. Authorizing Individual Title Email Address Firm Name Firm Address Firm Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Student Name Date Submitted (must be submitted by the end of the add/drop period in order to be considered for the current semester) I certify that the above-named applicant is employed by our firm and is eligible for tuition benefits for - Select -Fall semesterWinter semesterSpring semesterSummer semester Year Total Benefit Amount Payment will be made directly to - Select -Bloomsburg UniversityEmployee Affidavit - I understand the information provided in the form is subject to verification by Commonwealth University. This box must be checked to submit form. I certify that all of the information provided by me is true, complete and correct.
