TUITION REIMBURSEMENT APPLICATION

I hereby apply for consideration to be accepted in the Tuition Reimbursement Program. It is my understanding that acceptance is
contingent upon specific approval by Management of the course or courses I wish to pursue and the attainment of a “C” grade or better. I
understand that the calendar year maximum is $5,250.

PART I – TO BE COMPLETED BY EMPLOYEE

NAME:      
EMPLOYEE NO.:       DEPT:       TITLE:      
HIGHEST DIPLOMA/DEGREE AND YEAR GRADUATED:      
NAME OF INSTITUTION YOU PLAN TO ATTEND:      
LENGTH OF COURSE: QTR SEMESTER INTERIM SESSION
STARTING DATE:       ENDING DATE:      
OTHER Please define:      

Course Title Course Credit Tuition & Cost of Grade Received

Number Hours Fees Books (HR USE ONLY)
$
$
TOTALS

Is this course (or courses) part of a Degree, Certificate or Diploma Program? Yes No
If yes, Name of Degree, Certificate or Program:      

How is this program related to present job duties? If unrelated, to what position(s) within the company could this degree apply?
     

As part of the Tuition Reimbursement Policy Agreement, I hereby agree that if I voluntary terminate my employment within one year of
the course completion date that I will reimburse the company 100% of the reimbursement received during the 12 month period prior to
termination. I have also read, understand and agree to all the provisions of the Tuition Reimbursement Policy.

Employee Signature Date

PART II – TO BE COMPLETED BY MANAGER

Supervisor’s/Manager’s Recommendation:

Manager Signature Date

PART III – TO BE COMPLETED BY HUMAN RESOURCES

Application is approved for the following course numbers. The amount approved is       (percent or dollar value).

Application is denied for the following course numbers:

Reason for denial:

Human Resources Signature Date