Tuition Reimbursement Request Form

Revised August 1, 2015

Pittsylvania County Schools Tuition Request/Reimbursement Form for Teachers and/or Administrators

Pittsylvania County Schools will no longer submit tuition payments directly to the college or university. Tuition costs will only be provided as a reimbursement payment to the teacher and/or administrator requesting the assistance. The request for reimbursement must be received no later than June 1 of the current school year. If the request IS NOT received by this date, the approval of payment will become null and void. Please complete and submit your request for funding prior to registration of a class.

Employee Name (Last, First MI) Base School Today’s Date

Home Address (Required) City State Zip Code Telephone Number Email Address

SSN Current Assignment Please Circle Your Current Type of License XXX-XX-______Collegiate Professional Postgraduate Professional Technical Professional Provisional Pupil Personnel Term (check appropriate boxes and fill in blanks) Course Start Date and End Date  Fall  Spring  Summer

List College or University Classroom  Yes  No Via Web Yes No Course # Course Title Credits Days (e.g., MWF) Times (e.g. 2-4) Cost:

If funding is available, amount will be approved for one course at 100% up to $500 per semester. Please Check the Appropriate Box:  I wish to apply for tuition reimbursement, not to exceed the cost of tuition per class, in the amount of $______for the course listed above.

 I wish to request reimbursement of fees for successful Praxis II Assessment for an additional endorsement Must submit receipt of scores and payment. (List Area)

Tuition Reimbursement excludes the cost of books, e-Books, registration fees, comprehensive fees, student activity fees, resource fees, online fees, online fees, and capital outlay fees.

Employee Signature______Date______

PLEASE SUBMIT ORIGINAL FORM OR FAX TO (434) 432-9560 TO THE ATTENTION OF MONICA T. GLASS AT THE SCHOOL BOARD OFFICE For the Department of Administration Use ONLY

 This application is approved for $ for the course listed above. Please return copy of this form with tuition payment receipt, documentation of course completion and passing grade to receive tuition reimbursement up to a maximum of $500.00. Your reimbursement check will be mailed to your home address.

Funding Source:  Tuition Assistance  Eisenhower

 This application for funding is denied. Reason(s) listed below: □ Course is not in endorsement area. □ Funding is depleted for the current fiscal year. □ Other:

Signature______Date Assistant Superintendent for Administration