Tuition Reimbursement Form

(Continuing Applications Only)

For consideration by the Grant Committee, please fill out this form and submit with your

receipts.

Name: _________________________________________________________________

Age: __________

Years Employed at PNB: ___________

Program/class(es) you are taking: _____________________________________

Name of school or institution: ________________________________________

Time Frame: _______________ to _______________

Total Dollar Amount of Request: $___________________

Tuition: $____________________________________

Other costs: $________________________________

Would you like to meet with the Committee? Yes_______ No_________

Additional information:

If your overall career goals have significantly changed since your initial application to the Grant

Committee, please describe in the space below.

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Second Stage Tuition Reimbursement Form – rev Nov2011

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Parent category: Business