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<br />. ( \ ... <br /> <br /> <br />tervi[[e <br />'LstaEflsfiu! 11>57 <br /> <br />City of Centerville <br />Tuition Reimbursement Form <br /> <br />Complete this section and receive approval prior to enrolling in this course. <br /> <br />Employee Name: <br /> <br />Job Title: <br /> <br />Department: <br /> <br />Class Name: <br /> <br />*Attach course description <br /> <br />Class Dates: <br /> <br />to <br /> <br />How does this class relate to your job? <br /> <br />Estimated Tuition Cost: $ <br /> <br />Name of School: <br /> <br />Address of School: <br /> <br />Are you working toward a degree? <br />If yes, list degree <br /> <br />Employee Signature: <br /> <br />Yes <br /> <br />No <br /> <br />Date: <br /> <br />Pre-Approval Signatures & Funding Source: <br /> <br />City Administrator Signature: <br /> <br />Date: <br /> <br />Department Head Signature: <br /> <br />Date: <br /> <br />Account Coding: <br /> <br />Reimbursement Request Section - Complete after class is finished. <br /> <br />Date Class Completed: Final Grade: . <br />* Attach copy of grade sheet - Employee must receive a passing grade (C or equivalent) in order to receive <br />reimbursement <br /> <br />Actual Tuition Cost: <br /> <br />* Attach receipt for tuition <br /> <br />Employee Signature: <br /> <br />Date: <br /> <br />City Administrator Signature: <br /> <br />Date: <br /> <br />Department Head Signature: <br /> <br />Date: <br /> <br />50 <br />