TUITION REIMBURSEMENT APPLICATION FORM


First Name	Last Name

Home Address

City	Zip Code

Email Address


Building	Position

The following information is for data collection purposes only:

Area of Certification/Licensure

	JUNE,
Certificate/License Type	Date of Expiration

Do you have an approved Individual Professional Development Plan (IPDP) or Class Change Form on File?

Do the courses for which you are requesting tuition reimbursement address your IPDP or Class Change Plan goals?

Request for Reimbursement

(Please complete additional electronic forms if requesting more than one course)

College/University

Title of Course

Number of Graduate Credit Hours

(Hour Type)

Term/Date of Course

Begin with the TOTAL dollar amount of your anticipated tuition bill (minus any fees, rebates, etc.) and divide this TOTAL by the number of credit hours for the course.

This is your "Tuition Cost Per Hour".

Enter the cost of EACH credit hour in the space(s) below beginning with the most expensive hour(s).

Example: 3 Semester Hours/$1041.00

Total Cost = $347.00 Per Hour

Tuition Cost First Hour	$347.00
Tuition Cost Second Hour	$347.00
Tuition Cost Third Hour	$347.00
Total Tuition Cost	$1041.00

Note: Partial credit hours should be determined and entered using this formula as well.

PLEASE ROUND TO THE NEAREST CENT.

Tuition Cost First Hour
Tuition Cost Second Hour	*
Tuition Cost Third Hour	*
Tuition Cost Fourth Hour	*
Tuition Cost Fifth Hour	*
Tuition Cost Sixth Hour	* Complete these fields only if they apply to your single* class

Total Tuition Cost

(Exclude any other forms of reimbursement, rebates, etc.)

Click SUBMIT to send your application to the Tuition Reimbursement Committee.

You will receive an email confirmation once the committee begins to process your application.

You may PRINT a copy of the next page for your records.

Thank You for Using the Electronic Tuition Reimbursement Form!