Tuition Reimbursement Request Form

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Tuition Reimbursement Request Form
In order to be reimbursed for completed programs please fill out the following information. You will need to submit this along
with receipts and proper documentation for completion of course.
Office Use Only, do not complete
Date:
IDP with Manager Signature
Employee Name:
Signed Repayment
Commitment Form
E-mail Address
Transcript of Courses
Phone Number
Detailed Receipts
Department
Verification of GPA
Title
Please identify which program you are requesting reimbursement for:
Percentage of Reimbursement
Undergraduate Degree
Certification
Name of Program or degree
Examination
Conference
Master's Degree
PhD
Courses/Program Completed
Tuition Amount
Fees
Total
Please attach a transcript of courses for verification
Total
Semester G.P.A
Total Amount Reimbursed based on
GPA
**Please allow a minimum of 30 days to complete the reimbursement process.
I have read and understand the MTM Tuition Reimbursement Policy and agree to the terms of the policy.
Employee Signature
Date
People & Culture
Payroll Approval
Approval

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