Sample Tuition Reimbursement Request Form

by Patricia Lotich on July 16, 2010

Part of a tuition reimbursement policy is a corresponding tuition reimbursement request form. The request form should be completed by employees who request tuition reimbursement. Every organization should have a structured process to complete and submit the reimbursement request and should be considered a human resources management function and part of a comprehensive employee benefits package.

This is merely a template for the tuition reimbursement form and can be formatted in a word file.

ABC Company Name
Tuition Reimbursement Request Form

This form should be completed and a photocopy should be sent to Human Resource. The original form and supporting documents should be given to the department head. Forms must be completed and final approval received prior to the first day of class.

Employee Name: ____________
Phone Number: _____________
Address: __________________
City/Zip Code: ______________
Social Security #: ____________
Department:________________
Job Title: __________________
Name of School: _____________
Proposed Course is:
□ Undergraduate Course Credit
□ Graduate Course Credit
Course Number: ______________
Course Title: _________________
Credit Hours: _________________
Course Begins: _______________
Course Ends: _________________
Tuition, Fees and Itemized Receipts Required

Are courses for a credit leading to a degree?
□ Yes □ No
Name of Diploma/Degree: __________
Major Field of Study: ______________

Are you receiving VA benefits or other educational financial support?
□ Yes □ No
If yes, what assistance?  ___________

Attach supporting documentation addressing the following questions and any other comments:
How does the proposed course of study relate to your job assignment/position duties?  ______________________
If the course meets during your normal work hours, how will your work schedule be adapted? ___________________
How will the course-provided knowledge/techniques improve your performance and be useful to the company?  ___________________

I have read and understand the Tuition Reimbursement Policy and agree to the terms of the policy.
Employee Signature: ______________
Date: ________________________

Review and Signatures:
Department Head will review, sign off and forward to HR, even if not approved.
If approved, HR will send copy to employee. HR will also e-mail notice of approval to the employee and employee’s department head.
If request is not approved, HR will inform the parties of the decision.
Department Head Signature: ________
Date: ________________________
□ Approved □ Denied
If denied, state reason: ____________

Human Resources Signature: ________
Date: ________________________
□ Approved □ Denied
If denied, state reason: ____________

This tuition reimbursement request form should accompany the tuition reimbursement policy. This template should be modified to meet the needs of your particular organization.

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