Tuition Reimbursement Approval/Request Form Name: _______________________________________ Date: ________________________ Degree:
Associate’s
Bachelor’s
Master’s/Doctorate
Degree Name: ______________________________________________________________ College/University: ______________________________ Semester/Year: _______________ Course Listings COURSE TITLE
START DATE
END DATE
COST
GRADE*
*Attach a copy of course schedule and fees. *Send a copy of grades to HR upon course completion. **See the Employee Handbook policy for more details on the program. Annual Max Reimbursements Assocaite’s Degree: $1,500 Bachelor’s Degree: $3,000 Master’s or Doctorate Degree: $4,000 By signing below, if my request is approved, I understand that if I am no longer employed with GBA within one year of course completion, I will be required to pay back funds received during the last 12-month period and the money I owe to GBA will be deducted from my final paycheck. ______________________________________ Employee signature
____________________________ Date
______________________________________ Group Leader signature
____________________________ Date
……………………………………………………………………………………………………………… …………………. For HR Use Only – Do not write below this line. Total cost of courses taken: _______________ Amount eligible for reimbursement: ________________
Approval: Human Resources: _________________________________________________________________________ (signature) (date) Denial: Reason:_____________________________________________________________________________ _______