Pittsylvania County Schools
Application for EISENHOWER Funding (Title II, Part A) JULY 2012
for College Credit Course
Applicant must complete this form and submit it for approval to the Assistant Superintendent for Administration PRIOR TO REGISTRATION.
A COPY WILL BE RETURNED AND MUST BE SUBMITTED TO THE REGISTRAR WHEN REGISTERING FOR THE COURSE.
QUALIFYING AREAS OF INSTRUCTION (Federal Core Content)
Priority approval will be given to the following: Provisional Licensure, Renewal of Licensure, Add-on Endorsements in Needed Areas (Science & Math)
Only courses in the federal core content areas as noted below will be considered as allowable under Title II, Part A tuition funding.
Science History Geography English Art
Math Civics Government Reading Foreign Language
Economics Language Arts Music
If funding is available, amount will be approved for one course at 100% up to $500 per semester.
PLEASE PRINT OR TYPE
Name in Full
Social Security # School
Street or P.O. Box City State Zip Code
Position Current Assignment
License Held License Expires June 30,
Endorsements Have you applied for Tuition Assistance from Human Resources?
I will attend
Name and address of College or University
I shall take the
Course No. & Exact Title Credit Hours (sem/qtr.)
Date(s) of Attendance ______________________________________________ *Tuition Cost for Course $ _________________
Semester: (Place an X in the appropriate box) Summer Fall Spring
I am enrolling in this course for the reason(s) checked below:
To meet the requirements for a provisional license, to become highly qualified or an endorsement in a federal core content area in which I
have been assigned. Specify type of license or endorsement required: _______________________________________________________
To renew my license with the same endorsement(s). (Renewal date within one year)
I agree to repay the School Board any tuition assistance I received if I withdraw or fail to receive a passing grade from the course mentioned above.
Mandatory fees and/or course fees are the responsibility of the student. Items excluded from tuition assistance funding are books, e-books, registration fees,
comprehensive fees, student activity fees, resource fees, online fees and capital outlay fees. These fees should be paid before registering of classes.
I understand that it is my responsibility to notify Monica Glass at the School Board Office prior to the registration date if I cannot take or do not successfully
complete the class.
Applicant’s Signature Date ____________________________
(This form must be approved and provided to the college at the time of registration.)
TO BE COMPLETED BY THE ASSISTANT SUPERINTENDENT FOR ADMINISTRATION
____ Request for funding is approved in the amount of $ ____________ for the course above.
____ Request for funding is denied. Reason(s) listed below.
Funding is limited to federal core content areas classes and provisional licensure requirements.
Course is not in endorsement area. License renewal date is not within a one year period.
Funding is depleted for the current fiscal year. Other _____________________________________
The Pittsylvania County School Board may pay the above amount directly to the college upon certification from the college that the
student has enrolled in the course. This certification should be mailed to:
Dr. Lillian D. Holland
Assistant Superintendent for Administration _____________________________________________________
Pittsylvania County Schools Dr. Lillian D. Holland, Assistant Superintendent for Administration
P. O. Box 232
Chatham, VA 24531 Date _________________________________________________