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    PALS Reimbursement Form

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    bausha elliott
    This document is a tuition reimbursement application form for an employee seeking reimbursement for coursework. It requests information such as the employee's name, department, academic details of the courses, and requires approvals from the employee, administrator, and department head. Upon completion, the form and documentation should be returned to the Tuition Reimbursement Office for processing.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    PALS Reimbursement Form

    Uploaded by

    bausha elliott
    29 views1 page
    This document is a tuition reimbursement application form for an employee seeking reimbursement for coursework. It requests information such as the employee's name, department, academic details of the courses, and requires approvals from the employee, administrator, and department head. Upon completion, the form and documentation should be returned to the Tuition Reimbursement Office for processing.

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    Original Title

    PALS reimbursement form

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    This document is a tuition reimbursement application form for an employee seeking reimbursement for coursework. It requests information such as the employee's name, department, academic details of the courses, and requires approvals from the employee, administrator, and department head. Upon completion, the form and documentation should be returned to the Tuition Reimbursement Office for processing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views1 page

    PALS Reimbursement Form

    Uploaded by

    bausha elliott
    This document is a tuition reimbursement application form for an employee seeking reimbursement for coursework. It requests information such as the employee's name, department, academic details of the courses, and requires approvals from the employee, administrator, and department head. Upon completion, the form and documentation should be returned to the Tuition Reimbursement Office for processing.

    Copyright:

    © All Rights Reserved
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    of 1

    Payroll

    Tuition Reimbursement Application


    EZID # (REQUIRED) FALL
    YEAR PLEASE CHECK (√)
    WINTER
    SPRING 2 0 MOSES CMO/EHIT
    SUMMER WEILER NORTH
    CHAM MMG
    Instructions: Employee completes and department Supervisor/Administrator signs approval. Send form to Tuition Office forty five days from beginning of
    course. After course is completed please send copy of bursar receipt and grades.(Service Agreement if applicable) Please do not send originals
    NAME (LAST,FIRST,MIDDLE) DATE OF HIRE STATUS F/T P/T

    CLASIFICATION
    ___________________________________________________________________ M M D D Y Y RN PT PA MGMT
    EMPLOYEE

    TITLE DEPARTMENT WORK PHONE NUMBER

    ______________________________________________ _____________________________________________ ( ) _________________________

    EMAIL CONTACT PHONE NUMBER ( )

    ACADEMIC INSTITUTION MAJOR AS BA MASTERS PHD EXAM


    INFORMATION

    _______________________________________________________ _________________________________
    ACADEMIC

    CERTIFICATION TITLE (RN ONLY) CREDITS COMPLETED CREDITS NEEDED FOR DEGREE

    _______________________________________________________
    ANTICIPATED GRADUATION DATE CAREER/JOB INTEREST

    COURSE TITLE CREDITS


    COURSE INFORMATION

    COST PER CREDIT $

    1. TOTAL TUITION COST $

    2. REGISTRATION FEES $

    3. OTHER FEES $

    4.

    TOTAL CREDITS TOTAL COST $


    PLEASE SIGN AND PRINT SIGNATURES LEGIBLY
    EMPLOYEE SIGNATURE ADMINSTRATOR APPROVAL

    _________________________________________________ __________________________________________________
    DEPARTMENT APPROVAL

    PRINT PRINT

    ________________________________________________________ ___________ __________________________________________________ ___________


    SIGN SIGN
    DATE DATE
    DEPARTMENT HEAD APPROVAL

    ____________________________________________________
    PRINT
    I HAVE READ THE TUITION POLICY V-18
    ____________________________________________________
    ___________ EMPLOYEE INITIALS ___________ SIGN ___________
    DATE DATE

    SERVICE AGREEMENT
    $_______________________________________
    HRD USE

    REIMBURSEMENT AMOUNT
    ONLY

    APPROVED BY HUMAN RESOURCES TUITION OFFICER _________________________________________ DATE________________________

    Return to the Tuition Reimbursement Office


    111 East 210th Street, Bronx, NY 10467
    Email to: [email protected] Fax to: 914-349-8584
    Office phone Number: 914-349-8563

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