APPLICATION FOR TUITION REIMBURSEMENT

Name:      __________________________________       Department:      ________

School:      _________________    Term:               Charge per Credit Hour:      __

Please state the degree (if any) that you are pursuing:      ________________________

Is this your first application for reimbursement?    Yes             No

If so, please attach a brief outline of study and relationship to your short- and long-term employment goals. 

Courses for Reimbursement: 

            Credit Hours                                        Course Name                                Amount

                                                                                      Total Amount:                   

                                                                        Total to be Reimbursed:                              

Approval: 

Director of Human Resources:  ______________________________________________

Department Head:  ________________________________________________________

            I agree to comply with the provisions of the firm’s tuition reimbursement policy should I terminate employment with [Firm Name] within the time frame provided in the plan.  Further, I agree that the refund due [Firm Name] can be deducted from any unpaid wages due me upon my notice to [Firm Name] of my intent to terminate my employment.  (Any amount over & above my unpaid wages will be paid promptly to [Firm Name].)

                                                ________________________________        ____________

                                                Employee Signature                                          Date