Tuition Reimbursement Program Application/authorization Form
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23.460 RCUH Tuition Expense Reimbursement Policy
Attachment 2
RCUH Tuition Reimbursement Program
Application/Authorization Form
Instructions: You must complete this form and receive your Principal Investigator’ s review/endorsement prior to the start of the semester.
You must attach a copy of your Course Registration form to this Application Form. This form must be turned in to the RCUH Human
Resources Department no later than the close of business on the first day of classes in the applicable semester.
Please print or type the information below.
Date of Application:
Employee Name: ___________________________________________
Employee Number: ________________
Phone Number :___________________________________________
Employee Job Title: _________________________________ Email address: ______________________________
Principal Investigator(s): _____________________________ Project: ___________________________________
Name of College or University:
_________________________________________________________________
Course Name/Number: __________________________ ____ Number of Course Credits: __________________
Course Description (attach additional page if necessary):
_
_
_______________________________
Course Semester (check one):
Fall
Spring
Summer I
Summer II
Course Semester Year:__________
College Level (check one):
Undergraduate
Graduate
Graduate-Nursing
Graduate-CBA Masters
Medicine
Cost of Tuition (i.e., up to 3 credit hours, not including tax, dues, fees, books): $_____________________________
Explain how this course is related to your job (attach additional page if necessary): ________________________
_
_
Applicant Certification of Awareness:
I have read the RCUH policy pertaining to the Tuition Reimbursement Program and agree to abide by the requirements as stated. I
understand that I am responsible for my own tuition bills regardless of the amount of assistance provided by the RCUH.
Applicant Signature
Date
Principal Investigator’ s Review and Endorsement:
I have discussed the contents of this application with my employee, and I agree that the course is job related to his/her position description. I
am providing additional justification if this course is not directly related to my employee’ s position description (i.e., stated in the Minimum
Qualifications), however I believe the course has relevance to this employee’ s job.
Principal Investigator Signature
Date
Print Name
INTERNAL PROCESSING (RCUH USE ONLY)
FTE (%):________
Regular (Y/N):_______
Hire Date: ______ Other F.A.(Y/N):________ Verified by: _______
STATUS OF APPLICATION
APPLICATION IS APPROVED
APPLICATION IS DENIED DUE TO:_____________________________________________________
Director of Human Resources &
Chair, RCUH Tuition Reimbursement Program Committee
INTERNAL PROCESSING (RCUH USE ONLY)
Record of Course Completion (“ C” Grade or better)
Date Received
Authorization to Process Reimbursement
Effective July 1, 1997 (rev. 10/21/03)
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