5210601S Payroll PPM

APPLICATION FOR TUITION ASSISTANCE PROGRAM

Name:

Email Address:

Complete Address:

Home Phone:

Mobile Phone:

Work Phone:

Department:

Division:

Supervisor Name:

Supervisor Phone Number:

I have read and I understand City of Raleigh SOP 300-19. Have you been a full time permanent employee for at least 6 months?

YES NO

YES NO Hire Date:

I am applying for a:

Tuition Advance:

Tuition Reimbursement:

Other than from the City of Raleigh, are you receiving any assistance in paying for this schooling (VA, governmental, scholarships, grants, etc.)? YES NO If “YES” please explain:

I am taking this course to:

Prepare for a new job or position in the City of Raleigh. Maintain or improve skills in present job. Meet minimum requirements for present job. Other:

School Name:

Program or Major Name:

School Address:

Course Number and Title

Credit Hours

Tuition $ $ $

TOTAL:

$

Class Starting Date:

Class Ending Date:

Class Starting Time:

AM PM Class Ending Time:

AM PM

This course is a requirement for which degree? AAS_____ BS/BA_____ MA/MS_____ PhD_____ Other_____

I hereby agree to submit proof of successfully completing the course(s) to the Personnel Tuition Program Manager within 30 days of the ending date of each course. I also agree to repay the City of Raleigh any money I received or the school received on my behalf if I do not successfully complete the course(s) or if I leave the City of Raleigh’s employment within 90 days of completing the course(s).

Employee Signature:

Date:

Department Head/Designee Signature:

Date:

Tuition Program Manager:

Date:

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