Request for Education Assistance
Name: _____________________________________________ E Number: ______________________________________
Department: ________________________________________ Job Title: _______________________________________
Office Phone: _______________________________________ Cell Phone: _____________________________________
Date of Employment: _________________________________ FTE: ________________ Index: ____________________
Alternate work schedule requested: [ ] Yes [ ] No If yes, attach schedule.
Costs of the following courses/programs do not affect departmental budgets. See Program Policies.
Fee Waiver – One “for-credit” course per term up to 4 credits
Institution: ____________________________ Term: ____________________ Undergraduate: _____ Graduate: ______
Class period (days/time) (Ex: T TH 9-10)
Non-Credit Program
Institution: ____________________________ Term: ____________________
Class period (Ex: T TH 9-10)
Audit Program
Professional Development:
Continuing Medical Education:
Other:
______________________
Date and Time (Ex: T TH 9-10)
_________________________________________________________________________ ______________________
Applicant’s Signature D
ate
By signing above, I attest that have read and fully understand the requirements (as detailed in the appropriate sections of the programs
policy) related to my above stated request for educational assistance.
_________________________________________________________________________ ______________________
Supervisor Signature Date
By signing above, I approve the request and have addressed scheduling issues related to the employee’s attendance in the classes
detailed above.
_________________________________________________________________________ ______________________
Human Resource Officer Date
By signing above, I attest that the employee meets the program requirements for the request submitted.
Cost of Course or Program: $ ____________________________
_________________________________________________________________________ ______________________
Business Office Date
Version 9-17
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
