Rochester Institute Of Technology Application For Tuition Assistance
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1
2R
I
T
OCHESTER
NSTITUTE OF
ECHNOLOGY
Application for Tuition Assistance
See reverse side for information and instructions.
Employee Name: __________________________________
Employee No.: _____________________
RIT College/Division: _______________________________
RIT Phone #: _______________________
_____________________________________________
Check One:
College or University
(enter name)
Center for Professional Development (CPD)
Academic Year: ______________________ Semester:
Jan – Apr
May – Aug
Sep – Dec
Course Number: _____________
Course Name: ______________________________________________
Tuition Amount: __________________
Reimbursement Requested: ________________
(max of $750)
:
Yes
No, but will send within 45 days
Proof of Payment is Attached
(see reverse side for details)
reimburse me because I paid for the course (proof attached)
Check one:
advance me the reimbursement; I will pay for the course & send proof within 45 days
reimburse my department by journal entry to the following account (CPD only)
___ ___ . ___ ___ ___ ___ ___ . ___ ___ ___ ___ ___ . ___ ___ . ___ ___ ___ ___ ___ . ___ ___ ___ ___ ___
If you are seeking reimbursement for a credit course you are taking at an accredited college or university, please
describe how this course (not degree) will maintain or improve your current job skills; use specific comparisons
between your job description and the course description.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
If this request is for reimbursement for a credit course taken at an accredited college or university, the above
information accurately reflects the relatedness between my current RIT responsibilities and the course. I understand
that if I receive an advance on the reimbursement, I must provide proof of payment within 45 days of the
reimbursement or I will be required to repay the reimbursed amount to RIT.
__________________________________________________
____________________________
Signature of Employee
Date
Approvals:
_______________________________________
_________________________________________________
Print Name of Department Head/Director
Signature of Department Head/Director
Date
_______________________________________
_________________________________________________
Print Name of Dean of College or VP of Division
Signature of Dean of College or VP of Division
Date
NOTE: If your department head or director is also the Dean/VP, simply obtain the signature of the Dean/VP.
Human Resources Department Approval
Amount:
$750
Other $________
Payroll:
BW
Semi
____________________________________
___________________
Human Resources Benefits Assistant Review
Date
____________________________________
___________________
Human Resources Department Approval
Date
Rev 9/12
(see reverse side for information on reimbursement process)
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