VILLAGE OF PINEHURST
Tuition Assistance Application
Instructions prior to enrollment: 1. Complete Section I – Application. 2. Discuss proposed course with Department Director to be certain that it is eligible for reimbursement. 3. Courses must be taken on your own time, unless it is not available after working hours and time off work is approved by you Department Director and HR. 4. Complete Section I of this application and submit for approval prior to the start of the course . A copy will be returned to you after approval. KEEP THIS COPY WHEN RETURNED. After completion of the course complete Section III on the reverse side: 1. Attach receipt of payment, itemized bill detailing tuition cost, and official grade or verification of satisfactory completion to approved application. Forward your copy of the original tuition assistance application and attached documents to Human Resources for approval and reimbursement. 2. Reimbursements must be requested within sixty (60) days of course completion or else the tuition assistance commitment from the Village to you is voided.
Section I – Application
Employee Section
Name ____________________________________________________
Social Security Number ____________________
Position Title ______________________________________________
Date of Hire _____________________________
School to be Attended _______________________________________
Semester ________________________________
Course Title _______________________________________________
Days of Week/Time _______________________
Estimated Tuition for Course(s) _______________________________
Other Financial Aid Being Received:
Amount _________________ Provider _________________________________ Does Other Financial Have to be Repaid? YES NO
Course Information:
AS Degree BS/BA MA/MS
NON-Degree Course Challenge exam/CLEP
Other ___________________________
Describe specifically how this course contributes to maintaining/improving your current job skills (use back if needed)
I certify that the above is true to the best of my knowledge. I understand that tuition assistance is not an absolute right and is subject to supervisory and HR approval and the reimbursement is conditional upon satisfactory course completion, availability of funds, and that reimbursement may be subject to withholding and FICA taxes. I also understand and agree to the following: Termination of employment prior to the completion of a course voids reimbursement. This application will be processed according to the guidelines in the Tuition Assistance and Employee Training Policy. Voluntary termination prior to two years after the completion of a course requires a pro-rated repayment of tuition assistance from the date of separation in accordance with the provisions of the Tuition Assistance and Employee Training Policy.. Payroll deductions for the total tuition assistance paid to me will be made if I should terminate within a two-year period following completion of a course.
Employee Signature __________________________________________________________ Date ____________________
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