ATTENTION: This form is only for grades and receipts submission AFTER your application has been pre-approved by Human Resources and you have completed your course successfully per policy guidelines.

Employee Information

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School Information

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Program *

Course Information

Course Title 1
Course Title 2
Course Title 3
Course Title 4

Verification Checklist

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Reimbursement will only be considered for courses that are successfully completed with a grade of "C" or better for undergraduate courses or with a grade of "B" or better for graduate-level courses. If an incomplete grade ("I") is received at the end of the term, the class must be successfully completed and documentation submitted for reimbursement within thirty (30) calendar days after completion. The date that the incomplete grade is officially replaced with another grade is the date that will govern with respect to tuition repayment. For technical courses which require an examination to receive certification, the employee must pass the necessary exam within three months after completion of the course to be considered for tuition reimbursement unless an extension is granted. Extensions will be considered if the exam cannot be completed within the requisite three month period. Any such request for an extension must be submitted in writing to Total Rewards Wellness before the expiration of such three month period and shall contain an explanation with supporting documentation detailing why the extension is necessary.