City of Richmond
Human Resources Department
TUITION ASSISTANCE APPLICATION
Important Notice: Please read the Tuition Assistance Policy. After completion, send entire form to your Appointing Authority or designee.
APPLICATION FOR: (Check one) Fall Winter Spring Summer Year:
Social Security No. Name:
Present Address Street & Apt. No.
City: Zip Code: Home Phone:
Department: Bureau/Division: Work Phone:
Job Title: Date of Employment:
Name of School: Address:
List course(s) for which you are requesting assistance. (Attach verification of payment)
Course Title Start Date End Date
Cost per Credit Total Tuition
Explain how course(s) is (are) related to your work or to your field of endeavor. (Be specific):
Type of Program: Undergraduate Graduate Richmond Technical Center
Major or Certificate Sought:
Will you receive Financial Assistance from another source for the course(s) for which you are requesting Tuition Assistance? Yes
If yes, please list type of assistance: Amount:
In accordance with the Virginia Privacy Protection Act, the information requested will be used to determine your eligibility for Tuition
Assistance. I hereby apply for reimbursement in accordance with the established “Tuition Assistance Policy” and the requirements of the
Department of Human Resources. I have read the policy and I understand and agree to comply with its provision. I also certify that the
information above is correct.
Signature of Applicant: _____________________________________________
I have reviewed this application and recommend its approval.
Signature of Department Director or Designee: _______________________________________
Application for Tuition Assistance has been approved for reimbursement.
Application for Tuition Assistance has been disapproved
Department Coordinator____________________________________________ Date: ___________________
FOR DEPARTMENTAL USE ONLY
Date Application received:
Date Verification received:
Final Grade (s)
Date Received: Amount of Reimbursement: $
Payment: Approved Denied
Department Coordinator Signature: ____________________________________________ Date:
HR Form No. 26