2013-01-23 CC Packet - Laserfiche WebLink

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01/01/2013 City of Centerville Tuition Reimbursement Form Complete this section and receive approval prior to enrolling in this course. Employee Name: Job Title: Department: Class Name: *Attach course description Class Dates: to How does this class relate to your job? Estimated Tuition Cost: $ Name of School: Address of School: Are you working toward a degree? Yes No If yes, list degree Employee Signature: Date: Pre - Approval Signatures & Funding Source: City Administrator Signature: Date: Department Head Signature: Date: Account Coding: Reimbursement Request Section — Complete after class is finished. Date Class Completed: Final Grade: 'Attach copy of grade sheet — Employee must receive a passing grade (C or equivalent) in order to receive reimbursement. Actual Tuition Cost: ' Attach receipt for tuition Employee Signature: Date: City Administrator Signature: Date: Department Head Signature: Date: After the Reimbursement Request has been approved, send to the Finance Department with the original receipt and an expense report. Send a photocopy of completed Tuition Reimbursement Form to the City Administrator for inclusion in your personnel file. Page 51 of 51 Adopted 01/23/2013 71