HomeMy WebLinkAbout106.019 - FC-16, Tuition Reimbursement Application Form A
ADMINISTRATIVE MANUAL
FORMS
106.19 TUITION REIMBURSEMENT APPLICATION
FORM A (FC-16)
EFFECTIVE: SEPTEMBER 2008
Section 106.19
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INFORMATION SHEET
Form Number: FC-16
Title: TUITION REIMBURSEMENT APPLICATION - FORM A
Contents: Information for members seeking tuition reimbursement.
Refer to Administrative Order No. 6-11.
Frequency: As required.
Submission Date: No later than three weeks prior to enrollment.
Responsibility: Individual member.
Channels Through: Normal channels to the Financial Analysis Division
(Budget), Finance Department and/or City Manager.
Remarks: There are no guarantees of funds being available fo r
tuition reimbursement.
For additional information, refer to Administrative Manual,
Section 103.2, “Independent Education and Training”.
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Form A
Tuition Reimbursement Application
Section 106.19
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Note:
1. Each course must be completed with a grade of “C” or better for undergraduate work (“B” or better fo r graduate work) or “passing”
where no letter grade is given.
2. Request for reimbursement (completed Part II of Form A) must be submitted to the Budget and Management Studies within 65 days
following completion of course work.
3. Refer to the Administrative Order Manual, Instruction 1-11, for additional information.
Part I – Approval of Course(s) for Reimbursement
Instructions:
1. Complete Part I of this form, and submit to your department director to obtain approval prior to the beginning date of the course work.
2. Upon completion of the course work, fill out Part II and submit the original to your department along with grade(s) and all r eceipts.
Course
Number Course Title
Number
of Units
Course Date
Beginning and End Date
Time
Offered
Degree (specify major):
Enrollment at: CSUF FCC Other (specify)
Semester/Quarter: Fall Spring Summer Other (specify)
Undergraduate work Graduate work
Financial assistance: Are you now receiving, or do you intend to apply for, financial assistance payments or reimbursement for the above courses fr om any
agency or program (POST, Veterans’ Administration, GI Bill, financial aid (Cal Grant and/or Pell Grant), scholarships, etc.)?
No Yes (provide name of agency or program and amount of assistance):
Tuition reimbursement for the above courses will be approved only if the applicant agrees to and meets the following requirements:
1. Attendance is totally voluntary.
2. Attendance is outside the applicant’s regular working hours.
3. Applicant understands the course is not required by the City and nonattendance will not affect the applicant’s present working conditions
or continued employment.
4. Applicant will not perform any productive work for the City during attendance at course.
5. Applicant understands and agrees that any injury incurred during attendan ce at or while traveling to and from education courses is not
compensable under workers’ compensation.
I have read and agree to the above requirements:
Job Title Print Applicant’s Name Employee ID #
Signature of Applicant Date
Approved
Disapproved Department Director Date
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Form A
Tuition Reimbursement Application
Section 106.19
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Part II – Request for Tuition Reimbursement
Non-reimbursable costs and fees: Matriculation fees; test fees (except high school GED); diploma fees, graduation fees, costs for
damages or lost items; parking fees; insurance fees (except state health insurance); thesis reproduction costs; optional costs or fees; fees
of a personal or self-incurred nature.
Remember to attach all receipts, transcripts or grade cards and submit for reimbursement only for the courses that have been successfu lly
completed.
Amount
Expended Amount
Approved
Tuition (attach receipts and transcript or grade card) $ $
Required text books and materials (attach receipts)
Other reimbursable expenses (attach receipts with explanation)
Totals $ $
Signature of Applicant Date
Approved
Disapproved Department Director Date
Distribution: Original to Accounts Payable through BMSD One copy to Originator