Education Reimbursement Program
Pre-Approval Application for a Certificate/Certification Program
Revised 5/8/18
Please complete and submit prior to the beginning of a certificate/certification program.
Name: _____________________________ Department/Division: ___________________________
Employee Number: ___________________ Phone Number: ________________________________
Educational Institution/Private Certification Granting Agency: ___________________________________
Certificate/Certification Program Name: ____________________________________________________
Expected Month and Year of Certificate/Certification Program Completion: _______________________
How will this certificate/certification program benefit your current position or prepare you for
advancement opportunities?
Read and initial that you attest to each of the following statements. Initials
1. This course is voluntary, is not considered hours of work and/or employment, and no
compensation is earned.
2. I am an employee in good standing and have not received an overall rating of
unsatisfactory (2 or below) on a performance appraisal within the last twelve months.
3. I am a full-time/part-time benefited employee.
4. I must attach the certificate/certification program description for my supervisor to
review.
Employee Signature_____________________________________Date___________________________
For HR Use Only
Available balance before current request: $_______________ Estimated Reimbursement: $ __________
Approved: ☐ Yes ☐ No Comments______________________________________________________
HR Director/Designee Signature ___________________________________________ Date ____________
Estimated Cost
(Registration and books)
Approvals
1. I confirm that this Certificate/Certification Program will benefit the employee’s current or future
position.
2. I have reviewed the Certificate/Certification Program description and verified the educational
institution or private certification granting agency.
3. This employee is in good standing and has not received an unsatisfactory rating (2 or below) on a
performance appraisal within the last twelve months.
Supervisor Signature_____________________________________Date_________________________
Department Head Signature_______________________________Date_________________________
Comments__________________________________________________________________________
Please forward this form to HR upon completion.