Name: ________________________________________Title: ______________________________________Date: _____________
Contract/Tenure Status: ______________________________________________________________________________________
Unit: __________________________________________ Area of Teaching or Work: ___________________________________
Title(s) of Course(s):
________________________________________________________________________Credits: __________
________________________________________________________________________Credits: __________
Cost of Tuition per Credit: $__________ Total Credits: __________
Institution: _________________________________________________ Semester Enrolled:
Fiscal Year: _______________ Summer___ Fall___ Spring___
Are courses job related? (Please check)
If Yes, please explain. (This must be completed in the case of tuition reimbursement for graduate course work to determine if the
benefit is taxable)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Supporting reason for request (Include impact on professional development and courses you teach. Additional pages may be added.)
_______________________________________________________________________________________________________________
►_______________________________________ _________________________________________ ______________________
SIGNATURE OF EMPLOYEE Print Name Date
►_______________________________________ _________________________________________ ______________________
SIGNATURE (UNIT HEAD) Print Name Date
►_______________________________________ __________________________________________ ______________________
SIGNATURE (UNION REPRESENTATIVE) Print Name Date
RECOMMENDATION OF VICE PRESIDENT OR DEAN:
RECOMMENDED_____ DISAPPROVED_____
►________________________________________ _______________________
SIGNATURE OF VICE PRESIDENT/DEAN Date
RECOMMENDATION OF PROVOST:
RECOMMENDED_____ DISAPPROVED_____
►________________________________________ _______________________
SIGNATURE OF PROVOST Date
►ACKNOWLEDGEMENT OF RECEIPT BY VICE PRESIDENT, ADMIN. & FINANCE: ____________________________________
RECOMMENDATION OF EMPLOYEE RELATIONS
Priority Status –
(1) Those employees who are enrolled in a terminal or graduate degree program for which the employee previously received tuition reimbursement.
(2) Those employees embarking upon an approved terminal or graduate degree program.
(3) All other circumstances
RECOMMENDED_____ DISAPPROVED_____
►__________________________________________________ _____________
SIGNATURE (Assistant Director of Employee Relations) Date
