[Firm Name]

Tuition Assistance Program

Reimbursement Request

This Tuition Assistance Program agreement requests reimbursement for the education expenses pertaining to my studies and consist solely of tuition and textbook costs incurred by me during the preceding 12 months.  Attached is proof of expenses and successful completion of all courses for which reimbursement is requested.  Attached also is written pre-approval of the courses taken.

Employee Name:                                                                .

[Firm Name] Tuition Assistance Program Reimbursement Request

I hereby request reimbursement of $                                                                    for qualified

                                                                                                     (up to a maximum of $l,500 per year)

education expenses I incurred at                                                               .                   

Employee Signature                                                                .

Date                                                                .

Forward copy to [Name]  in Administration.

Approval for Payment                                                               .

Date                                                                .

File original in personnel file.