UAW-GM Tuition Assistance Plan (TAP)
Employee Application
(Office Use Only)
REMINDER: Completion Verification Required Within 60 Days of Your Term Ending Date
EMPLOYEE INFORMATION
(Please Print with Dark Ink or Type) Reimbursement Request, see Course Reimbursement Form at: www.uawgmjas.org or Click Here
Section I
Name ________________________________________________________________________________________________________________________________
GMIN #____________________________________________________________
First Middle InitialLast Address_________________________________________________________________________________________________________________________________________________
Street Number & Name Phone # ( Apt. #/PO Box
City/State/Zip Code
Change of Address must be made through your local plant HRD
) _____________________________ UAW Local # _________________________ Division/Plant Name _________________________________________
Current Employment Status (Check One):
 Traditional Active
 Entry Level
 Indefinite Layoff (Closed Plant Only)
 Military/Education Leave
Plant Cisco #________________________
 Surviving Benefits
Current Job Title _____________________________________________________________________ Email Address (Required) ___________________________________________________ School Student ID # _________________
COURSE/PROGRAM INFORMATION ONE TERM/PHASE PER APPLICATION
This section must be filled out completely – Incomplete applications will be returned. (Your Joint Training Representative (JTR) or school may assist)
Program Type (Check one)
(Office Use Only)
Section II
928881
 Job Related
 Personal Enhancement
Degree:
(Sports, Games & Hobbies
courses are not covered)
Other
Degree Name or Area of Study ___________________________________________________________
Maharishi University of Management
School Name ______________________________________________________________________________
 2 Year (Associates)
 4 Year (Bachelors)
 Graduate (Masters or Doctoral)
Term Begins ______________________________
Term Ends _____________________________
Month/Day/YearMonth/Day/Year
1000 North Fourth Street
Fairfield, IA 52557
School Address ___________________________________________________________________________
Course Number
(i.e. Eng 101)
ED 101
Street Number & Name
Course Title
(As shown in school course catalog)
Transcendental Meditation
City/State/Zip Code
Credit/Course
Hours (Per course)
2.0
Tuition*
Fee(s)*
Amount
Graduate
Level? Y/N
$1,000.00
* This Plan does not cover audited courses, test/exams, equipment/materials, add/drop or late fees, parking, etc.
The Plan does reimburse up to $200 per year for the cost of books for degree-related courses, see Book Reimbursement Form at: www.uawgmjas.org or Click Here
Section III
Fee Name
(List each fee separate)
Total Tuition
Cost and Fees*
$ 1,000.00
FINANCIAL AID/OTHER BENEFIT SOURCES (Excluding Loans)
Will you receive other financial aid or benefits (such as VA, scholarships or grants) to help pay tuition and/or fees for these courses?
 Yes  No
If Yes, indicate Source Name(s) ______________________________________________________________________________________________________________________________________________
Total amount specifically designated for tuition and fees $ __________________________________________________________________________________________________________
Section IV
AGREEMENT
As an eligible UAW-represented General Motors employee, I apply for approval of the above course(s) under the UAW-GM Tuition Assistance Plan. I understand that: (1) The UAW-GM Tuition Assistance Plan Administrators reserve the right to approve, or discontinue
participation/eligibility of an educational provider under the provisions of the Plan; (2) Tuition assistance will be subject to conditions contained in the Plan; (3) I am responsible for the payment of all non-approved costs and/or fees; (4) My employment status is not affected by
such training; (5) The participation is voluntary, not considered hours of work or employment and is not subject to compensation. In addition, I agree to provide whatever information required by the administrators of the UAW-GM Tuition Assistance Plan and that continuance
in the Plan is subject to meeting its provisions, including satisfactory course completion requirements. I further authorize any educational institution that I attend to release to the UAW-GM Tuition Assistance Plan any requested information pertinent to this Plan regarding
my status in said institution, including the release of a transcript or other information as outlined in the Plan.
I have read the above conditions of the Plan and agree to abide by them. Federal tax law may require General Motors to treat certain tuition assistance benefits as taxable income. As such, benefits under the Plan may be subject to withholding of Federal income tax,
FICA, applicable state and local taxes, as well as Form W-2 reporting. Please consult your Tax Advisor.
 I am an eligible UAW-represented General Motors employee and agree to abide by the terms and conditions of the Plan.
Applicant’s Signature _______________________________________________________________________________________ Date _________________________________ Rev. 5/2012
Telephone: 1-800-22 UAW GM (228-2946)
TDD (Hearing Impaired): 1-800-544-1186
Mail to: UAW-GM Center for Human Resources, Tuition Assistance Plan, PO Box 7840, Detroit, MI 48207-0840, Fax to: (313) 324-5050 or Email to: TAPHelp@uaw-gm.org