Tuition Reimbursement Form

Employee Name
Job Title
__
__
__

____________________
____________________

CPA Certificate
MST
Bachelors

__
__
__

Date
Division

_____________
_____________

Certificate(Name)_______________________
Masters (Name) ________________________
Other (Name) __________________________

Request for Tuition reimbursement:

Course Title 1______________________
Time Frame ______________________
Tuition Cost ______________________

Grade
________________
Credits Earned
__________
Credit Type
__________

Course Title 2______________________

Time Frame ______________________
Tuition Cost ______________________

Grade
________________
Credits Earned
__________
Credit Type
__________

Course Title 3______________________

Time Frame ______________________
Tuition Cost ______________________

Grade
________________
Credits Earned
__________
Credit Type
__________

Total Requested Reimbursement

$_________

For Reqwired tracking purposes, 1 credit hour of this program is equal to ___ hours
of training.
As per policy, tuition reimbursement is contingent on employee earning a B or
better in their coursework, and being an employee in good standing at this time.
As per policy, I understand that this reimbursement is contingent on my remaining
with GTM for six months after I receive the reimbursement. In the event that I
leave GTM prior to the completion of these 6 months, I will be required to
reimburse GTM for the total amount of this payment.
Employee Signature _____________________________ Date

______________

Approval (Educ. Coord.)

______________

_______________________ Date

Instructions: Employee should complete this form in its entirety. Attach documentation to support
your net payment for tuition and your grade transcript indicating an A orB grade. Once
completed, return to HR and/or the Education Coordinator who will submit it to Accounting.