PRELIMINARY APPLICATION FOR A TUITION EXCHANGE (TE) or CIC SCHOLARSHIP
(This form must be completed by employee and returned to the TE/CIC Liaison Officer before November
1st. A copy of the employee’s federal tax return providing dependent child status must accompany this
form.)
Eligibility to participate in the Tuition Exchange or CIC Scholarship Program is determined under
Guidelines adopted by Daemen College. Copies are available in the Personnel Office. Certification
of the applicant’s eligibility does not guarantee acceptance into the TE/CIC Program of the
institution the applicant seeks to enter. Member colleges/universities are generally able to offer only
a limited number of scholarships. Accordingly, the application process should be initiated in a timely
manner. Further, the employee must keep the TE/CIC Liaison officer at Daemen College informed
of the status of outstanding applications and communicate the applicant’s intention to attend a
particular college/university as soon as the decision is finalized.
Name of Employee:_______________________________Department:___________________________
Date Employed:
Home Address:
_______________________________ Staff Position/Title:_____________________
_____________________________________________________________________
Home Telephone: ______________________________________________________________________
Employee
Signature:______________________________________Date:__________________________________
Name of student applicant: ______________________________________________________________
Social Security Number:
_______________________Date of Birth:___________________________
Relationship to Employee: _______________________
Address (if different from above)_________________________________________________________
Names of TE/CIC Colleges or Universities applying to and course of study at each (attach separate sheet if
necessary):
______________________________________________________________________________________
At beginning of next academic year, applicant will be a college:__freshman,__sophomore,__junior__senior
Has applicant held a TE/CIC Scholarship last year or in any prior year:___Yes___No
If “yes”, is this an application for a __new or __renewed scholarship?
If “yes” name of the college/university attended?___________________________
If “yes” year(s) that the scholarship was held:_____________________________
Note: Students must notify, annually, in writing, the College TE/CIC Liaison Officer of acceptance
at host institution within thirty days, and of withdrawal or suspension. Students must also apply
annually, by January 15th, for re-certification of any scholarship awarded.
August 2011