Coursework Masters Support Scheme for Academic Staff Application Form (PG3)

Applicant’s details

Applicant’s name:
Appointment Level:	Choose an item.
Faculty / School:
Staff number:
Employment commencement date:	Click or tap to enter a date.
Appointment type:	Choose an item. <enter period for fixed term>

Current Academic Qualifications

Degree	Area / Major	Year Completed	University

Proposed Course Details

Course:
Course Code:
Faculty / School:
Start Date:	Click or tap to enter a date.
End Date:	Click or tap to enter a date.
Total Number of Sessions:

Please comment on the direct relevance of the proposed course to your current position.

< Enter text here >

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

Applicants Signature:	Date: Click or tap to enter a date.

COMMENT AND ENDORSEMENT BY HEAD OF SCHOOL

Do you support this application? Choose an item. <if other please specify here>

Please comment on how it is in the interest of the University’s academic program that the academic staff member obtains a coursework master’s degree.

< Enter text here >

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.

< Enter text here >

Are there any issues anticipated in meeting the performance required in relation to the “Standards, Expectations and Qualifications” in relevant academic activity areas?

< Enter text here >

Head of School’s Signature:	Date: Click or tap to enter a date.

Printed name:

APPROVAL BY EXECUTIVE DEAN

Do you approve this application? Choose an item. <if other please specify here>

☐ I acknowledge that funding has been approved from within the Faculty’s budget for the payment of course fees.

Executive Dean’s Signature:	Date: Click or tap to enter a date.

Printed name:

Endorsement: Senior Manager, DPC, Organisational Development

Signature:	Date: Click or tap to enter a date.

Senior Manager, DPC, Organisational Development

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 Charles Sturt’s Coursework Masters Support Scheme for Academic Staff.

Access to the information you provide is available to yourself, your Head of School, the Executive Dean and those persons authorised to access the information in the course of their duties to Charles Sturt.

This document will be stored by the Division of People and Culture on your personnel file

Coursework Masters Support Scheme for Academic Staff (Applicants’ 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 Executive Dean for approval

☐ The Executive Dean stores the original application (with recommendation and approval comments) and a copy of the admission offer on file

☐ The Executive Dean forwards a copy of the approval application and admission offer to the staff member and Head of School

☐ The Executive Dean forwards a copy of the approved application and admission offer as well as the original Residual Benefit Declaration to Division of People and Culture, PDPrograms@csu.edu.au.

Coursework Masters Support Scheme for Academic Staff – Residual Benefit Declaration

DECLARATION BY APPLICANT

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: Click or tap to enter a date.	End date: Click or tap to enter a 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% points. This declaration will also be revoked if another recurring residual benefit declaration is provided in respect of a subsequent identical benefit.

Signature:	Date: Click or tap to enter a 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% points or less.