Tuition Reimbursement Form
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1Tuition Reimbursement Form
LAST NAME
FIRST NAME
EMPLOYEE ID NO.
POSITION TITLE
PHONE NO. (Work or Cellphone)
EMAIL ADDRESS
WORK LOCATION
DEPARTMENT
Please indicate (“X”) which Bargaining -or- Meet & Confer Group you belong to:
AFT/Food Service
Management
(
)
AFT/ Maintenance & Operations
Police Officers Association
POA
AFT/Office Technical
Supervisory & Professional (SPAA)
Confidential (ACE)
Date
Class
Ended
Grade
(* see NOTE
Course
(HR
below)
use
CRN
Subject
No.
Course Title
Units
only)
Name of Accredited Institution:____________________________________________________________________
Total Amount Requested $________________ Official/sealed Transcript(s) attached?
(“Declaration”
YES
NO
(For amount requested, attach itemized receipts only-no bank or credit card statements)
must be attached)
* NOTE: Transcript(s) -OR- the Declaration of Official Grade Report Submission is required within 30 days (60
days for AFT: Office Technical/Food Services/Maintenance & Operations employees) following successful
completion of the class. For a complete description of the Tuition Reimbursement procedures, please refer to your
collective bargaining/group handbook. Payment request will not be processed without receipt of official transcript(s).
Employee’s Signature: ___________________________________________
Date: ___________________
-Human Resources Use Only-
Official Transcripts received:
______________ Declaration submitted-if needed:
________________
(date)
(date)
Revised Apr 2016
Approved Reimbursement Amount: $_____________________________ Employee Status: Active?
Y | N
(circle)
Approved by: ________________________________________________ Date: __________________________
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Parent category: Business