Tuition Reimbursement Request

In order to receive this benefit you must fit the following criteria:

You must be enrolled in an accredited institution for higher education and you also must be seeking a degree. We do not reimburse for certifications or vocational training.
Must have a "C" or better in a class to receive any reimbursement. Grades less than "C" will reduce your payment by a percentage that class was of your total hours attempted.
Must submit proof of grades and tuition (and book payment if a manager) within 30 days from the end of the semester.
Must be employed with Caspers Company/Oxford Commons at the time of payment of the benefit.
Must maintain satisfactory performance, cannot be on probation at the time of payment and you must maintain your work availability the entire semester.

First Name *

Last Name *

Last 4 of SS# *

Email Address *

Phone Number *

Street Address (your tuition check will be mailed here) *

Address Line 2

City *

State *

Zip Code *

What company do you work for? *

Job Title *

Name of College / Campus *

Term Start Date * +

Term End Date * +

Total Semester Tuition Costs *

Total Semester Book Costs (managers only) *

Attach schedule of registered courses for the semester requesting reimbursement *

Copy of Grades for the Semester applying for Reimbursement *

Please upload proof of payment of this semester’s tuition. The receipt must contain the following:

Your Name
The name of the college attended
The amount and date paid
Must be clearly labeled as a tuition payment

IMPORTANT: If your receipt shows financial aid, then please write in the space below the type of aid (i.e. student loan, Bright Futures scholarship, Pell grant, etc.) *

Book Receipts (Managers Only)

I believe I have qualified for the Tuition Reimbursement program. I understand that submission of this form does not automatically qualify me for reimbursement. I also understand that more information may be required of me if anything submitted is incomplete, or unclear. I understand that the process for reimbursement approval may take up to 4 weeks, and that any questions can be referred directly to the Human Resources Department. *

ACKNOLEDGEMENT