General Form - Tuition Assistance Plan Non-Harvard Course Reimbursement
ADVERTISEMENT
1
2General Form
Tuition Assistance Plan
HARVARD UNIVERSITY
Non-Harvard Course Reimbursement
Benefits
See Back for Guidelines
□□□□□□□□
Harvard ID #:
Department: ___________________________
Name: First __________________________ MI _______ Last __________________________________
Home Address: __________________________________ Daytime Phone: (______)_________________
City: _____________________________ State: ________ Zip Code: _____________________________
Date of Hire/Appointment: __________________________ Years of Service: _______________________
□
□
□
□
□
Employment Status:
Exempt
Faculty
Hourly
Post Doc
Support Staff (Non-Union)
I hereby certify that 1) I meet the eligibility requirements as stated on reverse side, and 2) will not
be covered by any other employer plan or any other person. My employer does not accept
responsibility for direct payment to any individuals other than the employee. I have read and
understand the information on this form.
_____________________________________________________ _______________________
Signature of Staff Member
Date
_____________________________________________________ _______________________
Signature of Immediate Supervisor
Date
_____________________________________________________ _______________________
Signature of Personnel Officer
Date
(except if you work in VPA, Financial Administration, or FAS)
□
□
□
□
1. Semester:
Fall
Spring
Summer
Full Year Course
□
□
2. Type of Credit:
Undergraduate
Graduate
3. School/Program offering the course: _____________________________________________
4. Course Number: _____________________________________ Credit Hours: ____________
Course Title: ________________________________________________________________
Course Start Date: ________________ Course End Date: ________________
□
□
5. Why this course is needed:
Requested by Supervisor
Pursuing Bachelor’s Degree
□
□
Pursuing M.L.S.
Upgrade skills/knowledge necessary for current job
□
Other: _________________________________________________________
6. Total Course Cost: $___________________ (tuition only)
7. Grade: _________ (If not available at time of application submission, may be supplied to
Crosby Benefit Systems within 60 days after the end of the course)
Mail to Crosby Benefit Systems, 27 Christina St, Newton, MA 02461
or Fax to 617 928 0001
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business