Tuition Reimbursement Application

Name*

Email*

I intend to register and will attend classes at the accredited institution listed below. I request approval in advance.

Registration Date*

Name of accredited school*

Course*

Course Number*

Credit Hours*

Tuition (price per credit hour)*

Start Date*

End Date*

My reason for enrollment is:*

A degree curriculum (please specify degree)*

I understand that I must attain an A, B or C grade in each course to be eligible for 90 percent reimbursement of tuition and registration only. There will be no reimbursement for a course grade lower than a ''C''. Upon completion of each course, I will submit the grade reports and tuition receipts to the Office.

Manager for reimbursement.
Reimbursement is limited to $1,000.00 per school year.
Educational assistance is not available to me under the G.I. Bill or a scholarship grant.
Educational assistance is available to me through an outside source; therefore, my participation in this program is only to the extent of tuition not covered.

Signature of Member (type name)*

Date*

Member Number*

REGISTRATION FEES ($)*

TOTAL GRANT REQUEST ($)*

TUITION REIMBURSEMET APPLICATION

Fill out the form below to apply for reimbursement.

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