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.
EMPLOYEE DATA
APPLICATION FOR: (Check one) Fall Winter Spring Summer Year:
Date:
Social Security No. Name:
Present Address Street & Apt. No.
City: Zip Code: Home Phone:
Department: Bureau/Division: Work Phone:
Job Title: Date of Employment:
COURSE INFORMATION
Name of School: Address:
List course(s) for which you are requesting assistance. (Attach verification of payment)
Course
Number
Course Title Start Date End Date
Credit
Hours
Cost per Credit Total Tuition
1 $
2 $
3 $
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
No
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: _____________________________________________
Date: ___________
DEPARTMENT RECOMMENDATION
I have reviewed this application and recommend its approval.
Signature of Department Director or Designee: _______________________________________
Date: ___________
DEPARTMENT OF
Application for Tuition Assistance has been approved for reimbursement.
Application for Tuition Assistance has been disapproved
Reason:
Department Coordinator____________________________________________ Date: ___________________
FOR DEPARTMENTAL USE ONLY
Invoice Number:
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
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