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12 -09 -09 <br /> Aterviffe City of Centerville <br /> �� Tuition Reimbursement Form <br /> Estabasked 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 /> 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 /> Pre - Approval Signatures & Funding Source: <br /> City Administrator Signature: Date: <br /> Department Head Signature: Date: <br /> Account Coding: <br /> Reimbursement Request Section — Complete after class is finished. <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 /> 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 to the Finance Department with the original receipt and an <br /> expense report. Send a photocopy of completed Tuition Reimbursement Form to the City Administrator for inclusion in <br /> your personnel file. <br /> Page 50of50 <br /> Adopted _,2009 <br />