№ lp_2_1_12081
Administrative government application form for employees requesting reimbursement of tuition expenses for graduate or undergraduate courses, including certification, agency recommendation, and internal approval records.
Form Number: C0-101
Revision Date: 10/2011
Document Type: Application Form
Subject: Tuition Reimbursement
Submission Deadline: Two weeks prior to the beginning of the course(s)
Required Attachments: Two copies of all receipts and proof of passing
Submission Deadlines for Receipts: February 1 (fall & summer courses); June 1 (spring courses)
Applicant Information Required: Name; TR Number; Employee Number; Collective Bargaining Unit Code; Home Mailing Address; Departmental Payroll Code; Title; Agency Name; Work Telephone Number; Work Address; Work Email Address
Course Information Required: Education Institute Name and Address; Course Title and Number; Number of Credits; Course Level (Graduate/Undergraduate); Job-Related Status; Course Start and Finish Dates
Financial Information Required: Charge per Credit; Total Credit Cost; Service Fee; Laboratory Fee; Other Fees; Financial Aid Received; Net Cost
Certification: Applicant Certification of compliance with tuition reimbursement regulations
Agency Review: Agency Approval Officer Recommendation and Signature
Coordinator Review: State Personnel Tuition Reimbursement Coordinator’s Decision
Internal Use Sections: Amount to be Reimbursed; Payment Request Date; Priority List Date; Department ID; Review and Processing Signatures
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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