s:\humanresources\4joni folder\forms\tuitionreimbursement - new form - in progess.docx 7/10/13
CSEA Educational Reimbursement Request
Request must be returned to you fully approved prior to the start of your course or you will not be
eligible for reimbursement.
Section I – Employee Information (To be completed by Employee)
x = ___________________ + ______________ = _______________
(tuition cost per credit hour) (# of credit hours taken) (total cost of tuition) (cost of text/s) (total cost requested)
A. Explain how this course is directly/indirectly related to your job or its promotional field.
(Attach additional sheet if necessary)
______________________________________________________________________________________________
______________________________________________________________________________________________
B. Financial Aid status
(Please select one)
___Yes, I am / ___ No, I am not receiving financial aid from sources other than loans, i.e. PELL, TAP, work study, state
funding, etc. (Students receiving non-loan financial aid should attach a copy of their financial aid award letter.)
C. Attach course description.
I hereby certify that the above information is true and correct:
____________________________________ ______________________
(Signature) (Date)
Section II (To be completed by Admissions Department)
Matriculated Student Non-matriculated Student
Date of Matriculation _________________
Major _________________
____________________________________ ______________________
(Signature – Director of Admissions) (Date)
Section III (To be completed by Human Resources)
Recommendation Approve Disapprove
Funds Availability Available Unavailable
Reimbursement Rate 100% 50% SUNY New Paltz or OCCC Rate (circle one)
____________________________________ ______________________
(Signature – Human Resource Officer) (Date)
Section IV (To be completed by the President)
Approve Disapprove
____________________________________ ______________________
(Signature – President) (Date)
