CentralOregonCommunityCollege
RequestforProfessionalDevelopmentFunds/Reimbursement
Administrative/AdultBasicSkills
Updated5/2015
\\FS2\Dept\Human_Res\WP\FORMS\ProfessionalDevelopment
Instructions:Pleasefilloutformcompletely,printandattachallreceipts,classschedulesandtranscriptstotherequest.Send
RequesttoHumanResourcesforprocessing.Seebelowforeligibleexpenses
Name:___________________________ _____________ DateRequested:_______________
Department:__________________________________ COCCIDNumber:_______________
AdministrativeorABS?__________________________ Fulltime/parttime:_____________
TelephoneExt.:________________________________ DateofHire:___________________
College/University:_____________________________ DegreePursued:________________
Pleasegiveadetailedaccounting/breakdownoftotalcostsforthisreimbursementrequest:
Totalamountapplyingfor:______________________
Priorfundsapprovedthisfiscalyear(July1June30):______________________
Breakdownofexpenses:
Tuition:________________
Books:___________________
Travel/Lodging:________________
Other:___________________
CheckRequesttofiscalservices:
Makecheckpayableto:______________________________________________________________
StreetAddressorOfficeLocation:______________________________________________________
______________________________________________________
City:_____________________________
State:__________________
Zip:________________
SignatureofApplicant:_____________________________________________________________
SignatureofSupervisor:_____________________________________________________________
(pleaseprintandsign)
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ForHRUseOnly:
ApplicationApproved:___________________ ApplicationDenied:_____________________
AmountApproved:____________________ Accounttocharge(s):
___________________
____________________
AuthorizedSignatureorbudgetadministrator:__________________________________________
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