Coursework Masters
Support Scheme for
Academic Staff
Application Form (PG3)
1.
Applicant’s details
Applicant’s name:
Appointment level:
 Academic Level A
 Academic Level B
Faculty/School:
Staff number:
Employment commencement date:
 Continuing
Appointment type:
 Fixed Term [please specify period of contract] ______________
2.
Current Academic Qualifications
Degree
3.
Area/Major
Year Completed
University
Proposed Course Details
Course:
Course Code:
Faculty/School:
Start Date:
End Date:
Total Number of Sessions:
4.
Please comment on the direct relevance of the proposed course to your
current position.
DECLARATION BY APPLICANT
I understand and acknowledge the terms and conditions that apply to the
Coursework Masters Support Scheme, as outlined in the Policy and Procedure, and
agree to abide by them if my application is approved.
I have attached  Offer of admission  Residual Benefit Tax Declaration Form
Applicant’s signature:
Coursework Masters Support Scheme: Application Form
Last reviewed: October 2011
Date:
Page 1
COMMENT AND ENDORSEMENT BY HEAD OF SCHOOL
5.
Do you support this application?
Yes
No
Other (specify)
6.
Please comment on how it is in the interest of the University’s academic
program that the academic staff member obtains a coursework Masters degree.
7.
Please comment on the need for professional development of the academic
staff member in relation to: the conditions of employment, probation review, or
performance review.
8. Are there any issues anticipated in meeting the performance required in
relation to the “Standards, Expectations and Qualifications” in relevant
academic activity areas?
Head of School’s Signature:
Date:
Printed name:
Coursework Masters Support Scheme: Application Form
Last reviewed: October 2011
Page 2
APPROVAL BY DEAN
8.
9.
Do you approve this application?
Yes
No
Other (specify)
I acknowledge that funding been approved from within the Faculty’s
budget for the payment of course fees.
Signature of Dean:
Date:
Printed name:
ENDORSEMENT BY DIRECTOR, ORGANISATIONAL DEVELOPMENT
Signature:
Date:
The personal information you provide on this form is protected by the Privacy and Personal Information
Protection Act 1998 (NSW). Provision of this information is a requirement of participation in CSU's
Professional Experience Scheme for General Staff.
Access to the information you provide is available to yourself, your Head of School, the Executive
Director / Dean / primary budget centre manager, and those persons authorised to access the
information in the course of their duties to CSU.
This document will be stored within the Division of Human Resources on personnel file.
Coursework Masters Support Scheme: Application Form
Last reviewed: October 2011
Page 3
Coursework Masters Support Scheme for Academic Staff
Applicant’s Checklist
Refer to relevant information in the policy and procedure for the Coursework
Masters Support Scheme.
Complete the “Application Form” (PG3).
Complete the “Residual Benefit Declaration”.
Photocopy your offer of admission.
Discuss your application and submit (a) the completed “Application Form”, (b)
“Residual Benefit Declaration” and (c) a copy of your offer of admission to
your Head of School for recommendation for approval.
The Head of School forwards the recommended application (as well as the
admission offer and the original Residual Benefit Declaration) to the Dean for
approval.
The Dean stores the original application (with recommendation and approval
comments) and a copy of the admission offer on file.
The Dean forwards a copy of the approved application and admission offer to
the staff member and Head of School.
The Dean forwards a copy of the approved application and admission offer as
well as the original Residual Benefit Declaration to the Director,
Organisational and People Capability, Division of Human Resources,
Wagga Wagga.
Coursework Masters Support Scheme: Application Form
Last reviewed: October 2011
Page 4
Coursework Masters Support Scheme for Academic Staff
Residual Benefit Declaration
I, _____________________________________ declare that THE COST OR
PART COST OF TUITION was provided to me by or on behalf of my employer during
the period:
Start Date ________________________ End Date _______________________
and that the benefit was used by me for the following purpose(s):
SELF-EDUCATION WHICH IS REQUIRED TO EARN A TAXABLE INCOME.
I also declare that had I purchased the service or privilege, etc for its market value, I
would have been entitled to claim an income tax deduction equal to 100% of the
purchase price.
I understand that this declaration is to apply to the above stated benefit and to any
identical benefit for a period up to 5 years from the date of this declaration or until the
stated percentage incurred in earning my assessable income decreases by more
than 10 percentage points. This declaration will also be revoked if another recurring
residual benefit declaration is provided in respect of a subsequent identical benefit.
Signature ___________________________ ________________________
Employee
Note
Date
Identical benefits are ones which are the same in all respects except for any
differences that are minimal or insignificant, or that relate to the value of the
benefits, or that relate to a change in the deductible proportion of 10
percentage points or less.