Application for Approval to Enroll in Job-Related Courses by Employee
1. Name: _____________________________________
2. Position: _____________________________ 3. Department: ____________________________
(attach job description)
4. Course Title: ___________________________________________________________________
. Institution or School: _____________________________________________________________
6. Please explain how this course relates to your current position (attach course description):
7. Starting Date: _________________________ 8. Completion Date: _______________________
9. Cost (attach documentation): _______________________________________________________
10. Employee Signature: __________________________________ Date: _________________
11. Supervisor Comments (Approve/Deny)
Supervisor Signature: __________________________________ Date: _________________
12. Department Head Comments (Approve/Deny) Is funding in the department budget? (Yes/No)
Department Head Signature:_____________________________ Date: _________________
13. Human Resources Comments (Approve/Deny)
Human Resources Signature: ____________________________ Date: _________________
14. Committee Recommendation (Approve/Deny)
Committee Chair Signature:______________________________ Date: _________________
If approved by Committee, and resolution approving the course is adopted by the Board of Supervisors, candidate may enroll and
e eligible for up to 50% reimbursement for costs in number 9 above. Employee must complete the course with at least a grade of
C, its equivalent, or better. Employee then submits a Tuition Reimbursement Voucher with receipts verifying costs as listed and a
copy of their final grade.
1. All requests must be approved by the Board of Supervisors prior to the start date of your class.
2. Complete sections 1 10 on the front of this form. Once complete, forward to your immediate
supervisor for review. When forwarding please be sure to include your job description, the course
description from the course catalogue, along with documentation for the amount you are
requesting. If you report directly to a Department Head, skip No. 11 and forward your request
directly to you Department Head for review.
3. Department Heads will review request and forward the form to Human Resources for review
regardless of whether they approve or deny the request
4. Human Resources will review request and forward to the Committee Chair for review regardless of
whether they approve or deny the request.
5. Oversight committee will review the request and determine if they would like to move the request
forward to the Personnel Committee.
6. If Personnel Committee approves, a resolution will go to the Board of Supervisors to approve.
Once the Board of Supervisors passes a resolution for your reimbursement, you will receive the
Warren County Tuition Reimbursement Voucher along with instructions on how to submit
documentation for reimbursement once you’ve completed your class.
ORM REVISED 2/2/2018
Instructions for Reimbursement of Approved Job Related Course(s)
Congratulations on completion of your Job Related Course! Below are some instructions to assist you in
getting your reimbursement in a timely manner.
T You must have actually paid for your tuition prior to reimbursement.
T Make sure the Warren County Tuition Reimbursement Voucher is completely filled out and
signed. The ‘Course/Book Titles’ column should be a title or description of the course, fees, or
books that you have paid for. The ‘Total Costs’ column is the total amount of the
tuition/fees/books charged by the college or bookstore. The ‘Financial Aid/Scholarships’ column
should include all monies given to you that you are not required to pay back. The difference
between ‘Total Costs’ and ‘Financial/Aid Scholarships is the ‘Total Out of Pocket Cost to
Employee’. The amount you will be reimbursed should be listed in the ‘50% reimbursement’
column. If you are filling out this form online the formulas should do the computations for you.
T You must provide a copy of your final grade(s) for th
e course(s) showing a grade of ‘C’ or better.
T You must provide a statement from the college showing the total cost for your tuition, fees, and
books as well as all payments applied to your account. Invoices or billing statements that do not
show payments are not acceptable. Books may be purchased from outside sources, but an
itemized receipt showing the title and cost of the book must be submitted.
T Any ‘free money’ should be listed in the ‘Financial Aid/Scholarships’ column. ‘Free money’ is
anything that you do not have to pay back. This figure does NOT include student loans or credit
card payments.
T Reimbursable fees are only those fees that are showing on your receipt as paid to the college.
Personal internet fees, mileage, etc are NOT considered reimbursable fees.
T Keep in mind that the amount on the resolution is a ‘Not to Exceed’ amount. That means that
you may not necessarily qualify for a reimbursement of that total. Also, if your qualifying
amount is greater than the NTE amount you will not be paid more than the NTE amount unless
your department head gets a new resolution.
ORM REVISED 2/2/2018
Reso #
Vendor #
Employee Name
Total Out of Pocket
50% Reimbursement
Cost to Employee
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
-$ -$
I, _______________________________, certify that the above reimbursement in the amount of $___________________ is true
and correct; that I have adhered to the Warren County Job Related Course Policy and that I am entitled to the above
reimbursement amount.
Approval for payment:
epartment Approval
Approved by:
This claim is approved and ordered paid from the
appropriations indicated above.
Date Signature Date Warren County Auditor
Warren County Tuition Reimbursement Voucher
Warren County Municipal Center
1340 State Route 9
Lake George, New York 12845
Employee Signature
Tax Exempt No. 14-6002576
Purchase Order No.
Total Costs (Including Fees)
Total Reimbursement Amount
Financial Aid/Scholarships