VCCS-16 Revised 11/2010
Virginia Community College System
Educational Assistance Request Form
Social Security Number
Empl ID (ID used SIS login)#
During Hours Study: Note: for classified employees an adjusted work schedule will be attached.
Leave of Absence With Pay: Promissory Note Must be Completed
Leave of Absence Without Pay: If educational expenses are being paid, promissory note must be completed.
College/University to be attended ________________________________________________
Time study will be pursued _____________________________________________________
*Limit of 6 credit hours per semester
Purpose of Assistance (Check One)
Job-Related: Supervisor’s signature verifies that course is related to current position responsibilities
Degree Requirement: Verification of acceptance into a degree program must be on file
Non-job related (after hours classes)
Payment Option (Check One) Note that IRS Tax regulations apply
Reimbursement: Contingent on receipt of a grade of “C” or better and supporting documentation.
Up-Front Payment: Promissory Note must be completed and attached to this form.
Waiver under the Continuous Learning Program (Educational Assistance Policy)
Date of Aid Request
__________________________ _________________ ____________________________________________
Employee Signature President’s Approval or Designee