TUITION ASSISTANCE APPLICATION

FOR USE AT CAMP LEJEUNE AND MCAS NEW RIVER ONLY

PRIVACY ACT STATEMENT
Under AUTHORITY of 5 USC 301 personal data is requested for the PURPOSE to use your SSN for identification to apply for tuition assistance. The
ROUTINE USE of this information will be included in your Education Record retained by the Navy College Office (NCO) or Marine Corps Education
Services Center. It will not be divulged without your written consent to anyone other than the U.S. Government and/or school personnel involved with
TA. For Navy, paper and/or electronic copies of the signed TA Application are retained at the originating NCO for three years and then shredded or
burned. For Marines, copies of the signed TA Application are retained at the originating Marine Corps Education Services Center and shall transfer
with the Marine to each new duty station. Copies of TA Applications and/or Authorizations for Officers are maintained in their Official Personnel Record
for two years following the completion of courses paid by TA. All other records are maintained in electronic format within the Navy College
Management and Information System (NCMIS) indefinitely. DISCLOSURE is MANDATORY in order to receive tuition assistance.
Instructions: Complete and submit this form (page 1 and page 2) to Lifelong Learning Camp Lejeune/MCAS New River
This form MUST BE SUBMITTED PRIOR TO TERM START DATE. This form MUST BE TYPED.
SSN : LAST NAME: FIRST NAME: MI:

BRANCH OF SERVICE: PAYGRADE: UIC OR MCC/RUC: YEARS OF EDUCATION: EAS (YYYY MM DD):

COMMAND ADDRESS: COMMAND PHONE: FAX NUMBER:

MILITARY EMAIL ADDRESS: WORK PHONE: ALTERNATE PHONE:

GI BILL ENROLLED IN: 1. VIETNAM ERA 2. VEAP 3. MGIB 4. EATP 5. NONE

IMMEDIATE ACADEMIC GOALS (Select Only One): GRADUATION INFORMATION: DEGREE PLAN INFORMATION:

1. High School Diploma 2. Vocational/Technical Have you applied for Graduation? Do you have a degree plan for the goal
YES NO listed? YES NO
3. Associate 4. Bachelor's
Will you graduate after completing this term? Do you have a SOCNAV/SOCMAR
5. Master's 6. Doctoral Agreement (Required for Associate &
YES NO
Bachelor Degree Levels)?
7. Professional (i.e. MD, JD, DDS, etc.) Grad Date (YYYY MM DD): YES NO

8. Continuing Education (CEU/Certificate)(Navy Only) School Issuing Degree: If yes, College:

NAME OF SCHOOL ATTENDING:

SCHOOL LOCATION: City: State: Country:

TERM START DATE (YYYY MM DD): TERM END DATE (YYYY MM DD):

Use the following information to enter the correct codes in the Course Description Blocks below:
(CD) COURSE DESCRIPTION (CL) COURSE LEVEL (PIM) PRIMARY (CU) CREDITUNIT
(Used to identify where or how the H = High School INSTRUCTIONAL MODE HOURS/TYPE
course is taught) E = Continuing Education C = CD ROM S = Semester
1 = On-Base (any military base) D = Developmental (Navy Only) I = Instructor Q = Quarter
2 = Off-Base V = Vocational/Technical P = Paper Based C = Clock
3 = Distance Learning L = Lower Level (Freshman/Sophomore) T = Tele Training K = Carnegie (High School)
4 = Credit by Examination U = Upper Level (Junior/Senior) V = Video Tape N = Continuing Education Units
5 = Deployed (Marine Corps Only) G = Graduate Level W= Web/Internet (Navy Only)
COURSE INFORMATION
Course Number of Cost Per Total
Course Title CD CL PIM CU Credit Credit Course
Department Number Hours Hour Cost

COURSE FEES (If Applicable)

Course Fee Description Total Fee

This TA Application is a request to my Education Center for a TA Authorization Voucher, to provide federal funds for my education.
Page Two has the applicant and command signatures required for authorization. Page One will not be accepted without Page Two.

MCBCL/MCCS/EDU/P1056.4/1 (01/07) (PREVIOUS EDITIONS ARE OBSOLETE) Designed using ADOBE 7.0 DESIGNER HQ/MCBCL Jan 2007
A. I understand acceptance of TA obligated me to the following:
1. To submit this TA application request to my servicing Education Center (Navy College Office or Marine Corps Education Services Center) PRIOR
to the start of the term. My TA Application will not be authorized by Navy or Marine Corps after the school’s late registration deadline or full tuition
refund date. Once my TA application is approved, I will receive a TA Authorization Voucher to take to the school for partial or full payment.
2. To personally deliver, fax, or mail my TA Authorization Voucher to the school during registration. If I register for courses PRIOR to receiving a TA
Authorization Voucher, I am liable for the full amount of tuition and course fees.
3. To pay the remainder of tuition and course fees not covered on the TA Authorization Voucher to the school.
4. To notify the Education Center (Navy College Office or Marine Corps Education Services Center) if any changes to the information on this
document occur, such as term dates or a different course other than the one on this form.
5. To notify the Education Center (Navy College Office or Marine Corps Education Services Center) if I do not enroll in any or all course(s) listed on
this form or if I cancel before the school’s drop/add date. If I cancel my course, I will provide my Education Center with the school’s verification of
the course cancellation.
6. To reimburse, via money order or cashier’s check payable to U.S. Treasury and mailed to NETPDTC*, tuition and fees paid on my behalf if I:
a. Voluntary withdraw from a course after the drop/add date or full tuition refund date and receive a grade of “W”.
b. Receive a failing (F) grade.
c. Fail to clear an incomplete (I) grade within six months of the original course completion date.
7. To provide my Education Center, if I receive a (W) grade due to an involuntary course withdrawal, a letter from my commanding officer confirming
withdrawal and resulting (W) grade was due to hospitalization, PCS, TAD, documented emergency leave due to the death of an immediate family
member, or a change in military duties or assignment. Reimbursement may be waivered if I officially withdrew based on one of these
circumstances and if I submit command verification to the Education Center.
8. To provide grades/certificates of completion to NETPDTC*. While I authorize the school I attend to forward a grade report or Certificate of
Completion to NETPDTC*, if my school fails to do so, I will be notified by NETPDTC*. It is my responsibility to ensure my grades areforwarded to
NETPDTC*.
9. To provide degree completion verification to my Education Center or NETPDTC*. While I authorize the school I attend to forward degree
completion verification to NETPDTC*, if my school fails to do so, I will be notified by NETPDTC*. It is my responsibility to ensure my degree
completion information is forwarded to NETPDTC*.
B. I understand failure to provide a grade report to NETPDTC* within 60 days of course completion or my failure to respond as outlined in
paragraphs 4 through 7 will lead to formal resolution/collection efforts such as a letter of indebtedness to my commanding officer and possible pay
checkage.
C. I understand if I am eligible for Montgomery GI Bill (MGIB) educational benefits, I may supplement TA through the MGIB Top-Up program. I
understand that I may not claim full MGIB benefits for the same courses on this TA application, as that would constitute a duplication of benefits from
the Department of Veteran Affairs. If I submit a Top-Up claim to the VA and then cancel the course(s) listed on this document, I will notify the VA
that the course(s) are not funded with Tuition Assistance.
D. If a Navy member pursing an undergraduate academic goal, I understand I should obtain a Degree Plan or SOCNAV Agreement (if applicable) by
the time I have 5 TA-funded courses. If a Marine pursuing an academic goal, I understand I should obtain a Degree Plan or SOCMAR Agreement (if
applicable) by the time I have completed 12 TA-funded semester hour equivalents.
E. For Navy Only: I am aware of the limitation of 16 Semester Hours (or the equivalent of 18 Quarter Hours, 180 Clock Hours, or 18 Continuing
Education Units) in effect for Navy Tuition Assistance. I certify that my request for TA does not exceed this limit, unless I have received an
authorized waiver from Naval Education and Training Command. If an administrative error results in the over-authorization of tuition assistance, I
will be expected to reimburse the Navy for the amount of the overpayment. If a not-reimbursable fee is included in my TA, and if I cancel the course
and no other courses are active at the institution for which the non-reimbursable fee is paid, I am responsible for reimbursing either the Navy, if they
pay this fee, or the institution, even if I do not incur tuition costs.
Commissioned Officers Only: By my signature below, I agree, in accordance with 10 USC 2007, to remain on active duty for two (2) years after
completing the course(s) on this form. This obligation runs concurrently with any remaining obligated service time. This agreement does not obligate
the military service to retain me on active duty. If allowed to voluntarily resign before my two year obligation is served, I will repay the government a
portion of TA expended on my behalf during my last two years of active duty in accordance with 10 USC 2005. Reimbursement of TA does not
negate the obligation.
* COMMANDING OFFICER All correspondence & payments should include:
NETPDTC TA ACCOUNTING N8115 a. Your full name d. Term Dates
6490 SAUFLEY FIELD ROAD b. Your social security e. Course name/number
PENSACOLA FL 32509-5241 c. TA Authorization Voucher Number f. School Name
Tuition Assistance is available under Federal Law 10 USC 2007. By my signature, I certify that I have read, understand, and will comply with all of the
governing voluntary education instruction and the provisions on this form. I understand I will pay all costs over and above the amount of tuition
assistance authorized.

APPLICANTS SIGNATURE: DATE SIGNED YYYY MM DD

The applicant's present or anticipated military duties will permit him/her to attend and complete the course(s) listed above.
THREE SIGNATURES ARE REQUIRED ON ALL REQUESTS

PRINTED NAME & RANK OF SNCOIC: SIGNATURE OF SNCOIC: DATE YYYY MM DD

PRINTED NAME & RANK OF OIC: SIGNATURE OF OIC: DATE YYYY MM DD

PRINTED NAME & RANK OF COMMANDING OFFICER: SIGNATURE OF COMMANDING OFFICER: DATE YYYY MM DD

Print Form Reset Form

MCBCL/MCCS/EDU/P1056.4/1 (01/07) (PREVIOUS EDITIONS ARE OBSOLETE) Designed using ADOBE 7.0 DESIGNER HQ/MCBCL Jan 2007