Staff Tuition Reimbursement Application
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1STAFF TUITION REIMBURSEMENT APPLICATION
Employee Information
Name:
Position:
Full Time:
Part Time:
Department:
Ext:
Schedule: _____ Hrs/Wk
_____ Mo/Yr
Supervisor:
Course/School Information
School Attending:
Course Title:
Dates:
From_____________
To______________
Degree Program:
Yes
No
Major:
Minor:
If Yes:
BA/BS
Other
Course Cost:
$
Brief Course Description:
How will the course content be of benefit to the College and you?
Increase skill and knowledge
Maintain skill and knowledge
Other, explain below
Are you eligible for other educational benefits: Yes
No
If yes, amount of aid less books: $___________________
I understand reimbursement is conditional upon satisfactory course completion.
______________________
_________________________________________
Date
Signature
Application must be signed by Department Head or Chair before sending to HR, see below.
APPROVAL
Approved
Disapproved
______________________
_________________________________________
Date
Department Head or Chair
REIMBURSEMENT APPROVAL
Notice of successful completion attached:
Amount of Reimbursement: $
Dept. Account: $
Lang Fund (Acct. #26002-5125-6612-41): $
Department:
Pay to the order of:
Human Resources Department:
Date:
TUITION REIMBURSEMENT IS PROCESSED THROUGH THE PAYROLL DEPARTMENT AND WILL BE
INCLUDED IN YOUR NEXT PAYROLL CHECK AFTER RECEIPT OF COURSE COMPLETION
MATERIALS (tuition bill/final grade).
HR 02/06
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Parent category: Business