Page 1 of 2 Revised 10/02/2013
This form must be submitted to Human Resources by the 3
rd
Friday of the month
CERRITOS COMMUNITY COLLEGE DISTRICT
REQUEST FOR PROFESSIONAL GROWTH PROGRAM
CLASSIFIED BARGAINING UNIT EMPLOYEES
Name:
Job Classification:
Full-Time
Part-Time
Title of Activity:
Division/Department:
Ext.
Description of Activity:
(Supply a copy of the brochure, agenda or program of the conference, workshop, seminar, etc., or specific titles and descriptions of each course.)
Date(s):
Times:
Location:
Please describe how this activity is related to your current job responsibilities and/or the manner in which the proposed coursework
will broaden your opportunity for promotion within the service of the District. If the course work is part of a degree program, also
include the proposed degree and the major:
Amount Requested:
Pre-Payment
Reimbursement
Conventions, Conferences, etc.
Educational Courses
Cerritos College Courses*
Registration Fees
$
Registration Fees/
Tuition
$
Registration Fees/
Tuition
$
Books/Materials
$
Books/Materials
$
Books/Material
$
Transportation
( ____x .56.5)
$
Parking
$
TOTAL
$
Other:_____________
$
Parking
$
TOTAL
$
Lodging
$
Meals
$
Other_______________
$
TOTAL
$
COMBINED TOTAL
$
*Cerritos College Coursework List:
Course Name
Course Number
Course Description
I certify that this is a reasonable estimate of expenses. If this request is approved, I agree to submit ALL original receipts to the
Office of Human Resource Services for reimbursement within ten (10) working days after completion of the approved activity.
Actual expenses more than estimated will be paid in accordance with the provisions of the attached procedures. VERIFICATION
OF COMPLETED COURSE WORK IS REQUIRED. I understand that failure to complete a pre-paid activity will require me to
reimburse the Professional Growth fund. I certify that these expenses are not being reimbursed from any other source. I further
understand that due to a change in the tax laws effective July 1, 1992, the District is required to report educational reimbursements
paid to employees as a taxable benefit and that it is my responsibility to contact my tax consultant to discuss my individual tax
liability at the time of filing my taxes.
_________________________________ __________________
Employee’s Signature Date
Page 2 of 2
(For Professional Growth Committee Use Only)
Recommendation:
Approved
Disapproved
Abstain
Approved
Disapproved
Abstain
Approved
Disapproved
Abstain
Approved
Disapproved
Abstain
Date Committee Reviewed
Approved Amount $__________________
_____________________________________________ _____________________
Chairperson, Professional Growth Committee Date
Comments __________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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