TUITION REIMBURSEMENT FORM

NAME___________________________________DATE_______________

HIRE DATE_______________________

NAME(S) OF CLASS(ES)_______________________________________

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SCHOOL_____________________________________________________

START DATE_________________END DATE______________________

COST PER CREDIT HOUR______________________________________

TOTAL COST OF CLASS(ES)____________________________________

COMMENTS__________________________________________________

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ALL CLASSES MUST BE TAKEN AT AN ACCREDITED COLLEGE. MAXIMUM TUITION REIMBURSEMENT AMOUNT PER PERSON PER CALENDAR YEAR IS $2,500.00. FEES AND BOOKS ARE NOT INCLUDED. GRADE OF “A” OR “B: WILL RECEIVE 100% REIMBURSEMENT. GRADE “C” WILL RECEIVE 50% REIMBURSEMENT. GRADE OF “D” OR BELOW WILL NOT RECEIVE REIMBURSEMENT.

PLEASE ATTACH A SCHEDULE AND PROOF OF COST.

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SIGNATURE

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GENERAL MANAGER

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DIRECTOR OF HUMAN RESOURCES