Tuition Reimbursement Request

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