Fillable Tuition Aid Application City of Little Rock

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Tuition Aid Application City of Little Rock

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BROWSE CITY (AR) FORMS

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Index No. 1010
Revised 8/07
City of Little Rock
Tuition Aid Application
Date of Request: ___________________________________________________
Employee Name: ___________________________________________________
Department: _______________________________ Division: ______________
Employee Number: _________________________________________________
Employee Job Title: _________________________________________________
Name of Institution: _________________________________________________
Course Title: ______________________________________________________
Class Schedule: ____________________________________________________
Employee Statement: I hereby request that the City of Little Rock reimburse me
for the educational expenses associated with the course desired above. I
understand that should I terminate employment with the City for any reason
within one (1) year following course completion, I will be personally liable to
reimburse the City 100% of the tuition assistance. If I should terminate my
employment after one (1) year, but before two (2) years following course
completion, I understand that I will be personally liable to reimburse the City
50% of the tuition assistance.
The City shall accordingly be entitled to recover any such amount from any
payments due me upon termination.
I also understand that I am required to provide all necessary receipts for incurred
tuition expenses as well as a copy of the related grade report to my Department
Director.
Signature: __________________________________ Date: _________________
Index No. 1010
Revised 8/07
City of Little Rock
Tuition Request
Employee Name: _________________________________________________
Date of Request: _________________________________________________
Department Director Approval
It is my determination that the course listed on the Tuition Aid Application will be of value to the
City of Little Rock. I have discussed this request with the employee, who understands the terms
under which the City agrees to reimburse the employee for tuition related expenses.
_________________________________________ _________________________
Department Director’s Signature Date
City Manager Approval
Request Approved: ______
Request Denied: ______
__________________________________________ _________________________
City Manager’s Signature Date
Department of Finance Use Only
Request Received: ___________________________
Account Charged: ___________________________
Amount Paid: ___________________________
($2,000 annual maximum)
Approved By: ___________________________
Date Paid: ___________________________
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Tuition Aid Application City of Little Rock

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Completed 21 March 2020

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