Section II – Course Approval
Employer Section
The proposed course is considered to be directly related to the employee’s work assignme nt or is part of a degree program that relates to a position here at the Village and is expected to be beneficial to job performance.
Department Head Signature __________________________________________________ Date _____________________
Human Resources Signature ___________________________________________________ Date _____________________
Section III – Reimbursement Request After Course Completion
Employee Section
Attached are grade report or verification of satisfactory completion and an itemized receipt of payment (cancelled checks are not acceptable) for the course approved above. REMINDER: Tuition assistance is only for the cost of tuition and associated lab fees and does not include books, or other miscellaneous educational expense.
I request reimbursement in the amount of $ ________________________________________
Employee Signature __________________________________________________________ Date _____________________
Se Section IV – Reimbursement Approval
Employer Section
The documents supporting the request for reimbursement are correct and comply with the approved policy.
Human Resources Signature ________________________________________________________Date_________________
Account Number for Reimbursement _________________________________________________
Employee Name __________________________________________________________________ Approval Amt_________ E
NOTE:
PLEASE KEEP THIS FORM TO RE-SUBMIT WITH YOUR GRADE AND PAYMENT DOCUMENTS ORDER TO RECEIVE YOUR REIMBURSEMENT.
G:HR/Policies/Tuition Assistance Application
7/15
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