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PATHWAYS EDUCATION PLAN  

Please print hard copy. This form can not be submitted electronically.

ELIGIBLE EMPLOYEES: To be eligible for PATHWAYS an employee must be a regular full-time or regular part-time employee of a participating U S WEST entity (excluding BRI and U S WEST DEX), with six months Term of Employment.

___$2100 Tuition  If you checked this option, PATHWAYS funding for your annual tuition, including personal development course costs is limited to $2100. Reasonable, eligible fees will be paid in addition to tuition.  Print this form, fill out information and fax to 303-773-9110.

___No-cap Degree Tuition - A consultant's signature and a copy of your degree plan are required for this option.    If you checked this option, as an active employee, your tuition for undergraduate degree programs is unlimited. Reasonable, eligible fees will also be paid. Print this form, fill out information and obtain consultant signature.  Go here for list of trained PATHWAYS Consultants.

___Essential Skills - A consultant's signature is required for this option.  If you checked this option, you will be taking the specific Essential Skills courses identified by the Essential Skills Task Force. Unlimited tuition and reasonable, eligible fees are paid.   Print this form, fill out information and obtain consultant signature.  Go here for list of trained PATHWAYS Consultants.

Eligible employees choosing the Essential Skills option may use this option alone or combined with either the $2100 option or the No-cap degree option.

Last Name_____________________ First Name           Middle initial ___________________________ SSN ___________________
Home address__________________________________________________________________________
City _____________________ State ____________ Zip____________
E-mail address   ___________________________________
Daytime Phone ________________________________ Evening Phone_____________________________
Term of Employment          /         /

___

occupational ___ management Birth date      /         /
Gender    F

M

       TOE date                               M    D    Y (optional) (optional)
I am separated/will separate under a separation plan. Date of separation          /           /

For each of the following categories, please circle the response that applies to you.

Highest level of education completed to date:
High school diploma or GED Some college 2-year degree 4-year degree Advanced degree
Ethnicity: (optional)
American Indian or Alaskan Native Asian or Pacific Islander Black
Hispanic White Other (specify)
Education goals: (circle the numbers of all that apply)
1. Further my education/increase skills 2. Certificate or license 3. 2-year degree
4. 4-year degree 5. Graduate level courses* 6. Advanced degree*
* Have you been denied TAP for graduate level or advanced degree courses? Yes No
Career goals: (circle the numbers of all that apply)
Within U S WEST
1. Employment Security 2. Advancement 3. New job 4. New career
Outside U S WEST
5. New job 6. New career 7. New job in addition to current job 8. Post-retirement career
My general area of study is: (circle the number of all that apply)
1. Liberal arts and sciences: English, math, social sciences, etc.
2.General education
3. Business or management courses 4.Computer/information science
5. Professional study: health care, education, etc.
6. Vocational/technical: telecommunications, electronics, word processing, etc. (specify) ___________________
7. Other (specify)   ___________________________________________________________________________
School(s) and course(s) requested: (must be completed or your Plan will be returned)
Name of school/provider _____________________________________________________________________
Address_______________________________________________    City_________________________________
Distance learning? (telecourse, correspondence, on-line, etc.) Yes_____ No_____
Degree Program? Yes____ No____ CREDIT? Yes____ No____
If Yes, please check one below: Personal development ($300 max)? Yes___No____

Undergraduate: Associate (2 year)
Undergraduate: Bachelor (4 year)
Graduate (Master's, Ph.D.)

Certificate/license? Yes____No_____
If yes, is certificate part of degree program? Yes____No_____
Major _____________________________________ NEAT certificate? Yes____ No__ _ If yes, please check the Essential Skills option and have this form signed by a consultant.
If non-degree, subject areas   ___________________________________________________________________________________
Additional School(s) and course(s) requested: (optional--you must have at least one school listed above)
Name of school/provider _____________________________________________________________________
Address_______________________________________________    City_________________________________
Distance learning? (telecourse, correspondence, on-line, etc.) Yes_____ No_____
Degree Program? Yes____ No____ CREDIT? Yes____ No____
If Yes, please check one below: Personal development ($300 max)? Yes___No____

Undergraduate: Associate (2 year)
Undergraduate: Bachelor (4 year)
Graduate (Master's, Ph.D.)

Certificate/license? Yes____No_____
If yes, is certificate part of degree program? Yes____No_____
Major _____________________________________ NEAT certificate? Yes____ No__ _ If yes, please check the Essential Skills option and have this form signed by a consultant.
If non-degree, subject areas   ___________________________________________________________________________________
___I am ___I am NOT receiving financial aid from any other source (i.e. grants, V.A. assistance, scholarships, other
U S WEST programs.) If receiving financial aid, please indicate the source: _______________________________________________________________________

As an eligible PATHWAYS participant, I understand that My Letter of Credit can only be used at schools or providers which are eligible per the PATHWAYS policy on eligible tuition and fees. I may be taxed on tuition, fees and books. I am responsible for all charges from an ineligible provider. PATHWAYS does not pay for purchase or rental of computers, equipment, including airplanes/fuel, tools, supplies; room, board and transportation.  Avocational or leisure-time activities, including sport, game or hobby courses, must be degree-related and documented as such to be approved for payment by PATHWAYS. If my status as a U S WEST employee changes, I must verify my eligibility with PATHWAYS before I continue to use my Letter of Credit. I am required to notify PATHWAYS immediately if I separate from U S WEST. I am responsible for expenditures that exceed the Letter of Credit amount.

I agree that I am responsible for any ineligible tuition charges.

Employee Signature ________________________________________________________     Date _______________________

Consultant signature required for Essential Skills option, no-cap degree option and Education Plan changes.
Consultant signature _______________________________________________________________ Date ______________
Consultant Name (please print) ________________________________________________________
FOR INTERNAL USE ONLY

Consultant Code______________   I-Code(s) 1_____________ 2__________   Approved by_________ Date ____________

You do not need an LOC to see a consultant.