Instructions:
Educational Assistance ApplicationDate: _______________________ Employee name: ____________________________________________________ Department: _______________________ Job title: _______________________ Course title: ________________________________________________________ Course dates: ____________________________ to ________________________ Degree sought (if applicable): ___________________________________________ Name of institution: ___________________________________________________ Address of institution: _________________________________________________ Course Expenses: Tuition: $___________ Fees $_____________ Books/materials $___________ Total cost $__________
Development objective (what long-term goal is this program/course intended to help you reach): ____________________________________________________________________________ If seeking a degree program, please attach a brief outline of the courses included in the program from the college catalog or program brochure (necessary for initial request only). I understand that if this request is approved, reimbursement will be contingent upon successful completion (a grade of B or better for graduate courses; a grade of C or better for undergraduate courses) of each course and submission of all receipts and paid bills within 30 days thereafter. I further understand that failure to successfully complete any course(s) will result in an obligation to repay [company name] the amount of tuition advanced. ___________________________________ ___________________________________
DEPARTMENT RECOMMENDATION[ ] Approved [ ] Not approved Reason: ________________________________________________________________
Does this application meet the established guidelines of the educational assistance program policy? [ ] Yes [ ] No Was this expense included in the department budget? [ ] Yes [ ] No ___________________________________ ___________________________________ HUMAN RESOURCE DEPARTMENT APPROVALThis request is [ ] Approved [ ] Not approved Reason (if not approved): _____________________________________________________
__________________________________ __________________________________ ADVANCEMENT
(to be made before course(s) begins)Date: ___________________________ Advance in the amount of $ ________________ is approved. Expense should be charged to ________________________________________
________________________________ ________________________________ REIMBURSEMENT
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