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City of Centerville <br />Tuition Reimbursement Form <br />Complete this section and receive approval prior to enrolling in this course. <br />Employee Name: <br />Job Title: <br />Department: <br />Class Name: *Attach course description <br />Class Dates: to <br />How does this class relate to your job? <br /> <br />Estimated Tuition Cost: $ <br />Name of School: <br />Address of School: <br />Are you working toward a degree? Yes No <br />If yes, list degree <br />Employee Signature: Date: <br />City Administrator Signature: Date: <br />Department Head Signature: Date: <br />Funding Source Account Coding: <br />Reimbursement Request Section – Complete after class is finished. <br />Date Class Completed: FinalGrade: * <br />*Attach copy of grade sheet – Employee must receive a passing grade (C or equivalent) toreceive reimbursement. <br />Actual Tuition Cost: * Attach receipt for tuition <br />Employee Signature: Date: <br />City Administrator Signature: Date: <br />Department Head Signature: Date: <br />After the Reimbursement Request has been approved, send the original receipt and an expense report to the <br />Finance Department. Send a photocopy of the completedTuition Reimbursement Form to the City Administrator for <br />inclusion in your personnel file.Reimbursement is subject to budget appropriation being available. <br />Page 59of 60 <br /> <br />