Tuition Reimbursement Form
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1Tuition Reimbursement Form
Employee Information
Employee Name:
ID/SSN:
Department:
Supervisor:
Position:
Extension:
Course Information
School/Instit.
Teacher:
Course Name:
Course No.
Term Length:
Term/Year:
Meeting Days:
Times:
Degree/Major:
Graduation Date:
Relevance to Work:
Course Required for Major?
Other Financial Assistance:
Reimbursement Requirements
q Relevant to Work/Major
q Course Completed
q Maintained a
grade or higher
q Minus Cost of Other Financial Aid
q Proof of Payment
q Other:
q Other
Reimbursement Receipt
Receipt No.
Date:
Employee Name:
ID/SSN:
Course Total Cost:
Other Costs:
Total Requested:
Total Approved:
Tuition Yearly Total:
Reimbursement Yearly Total:
Approver Name:
Approver Signature:
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Parent category: Business