Tuition Reimbursement Application
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Section III
(HR - Review Below and Complete)
HR Supervisor's Approval Status:
*
Please Select
Approved
Denied
HR Supervisor's Signature:
*
(a) Credits completed this form
*
(b) Cost per credit ($)
*
(c) Cost this semester ($)
*
(d) Reimbursement received this year
*
(e) Total (c + d)
*
(f) Amount to be Paid
*
Final Amount to be Paid
Last Update
-
Month
-
Day
Year
Date
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Section II
(Department Head - Review Below and Complete)
Employee's Last Performance Rating was a Full Contributor or higher?
Yes
No
Employee has no current corrective actions above an Oral/Verbal Warning?
Yes
No
Department Manager / Director's Approval Status:
Approved
Denied
Department Manager / Director's Signature:
*
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Section I
(Employee - Complete in full Prior to Beginning of Course)
Select Location:
*
BCAC
Carroll Hospital
Carroll Health Group
Grace Medical Center
Levindale Geriatric Center & Hospital
Northwest Hospital
PDI
Sinai Hospital
Employee:
*
First Name
Last Name
Employee ID #:
*
Department:
*
Job Title:
*
Phone Extension:
*
Cellphone #:
*
No parentheses or dashes
Scheduled Work Status
*
Full-time
Part-time
Begin Work:
*
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:
Hour
00
15
30
45
Minutes
End Work:
*
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:
Hour
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15
30
45
Minutes
E-mail Address:
*
example@lifebridgehealth.org
Manager/Director's E-mail Address:
*
example@lifebridgehealth.org
College/Institution:
*
$ Cost Per Credit:
*
Date Course Begins:
*
-
Month
-
Day
Year
Date
Date Course Ends:
*
-
Month
-
Day
Year
Date
Are you currently under a tuition payment plan for your educational expenses with your college or institution?
*
Yes
No
If yes, please upload your payment plan documentation.
Browse Files
Cancel
of
I hereby apply for Tuition Reimbursement for the following course(s):
Course No. and Title
No. of Credits
Scheduled Classes (days and hours)
1.
2.
3.
4.
Upload Grades
Cancel
of
Please upload your itemized statement for your course costs.
*
Browse Files
Cancel
of
Do you receive Financial Assistance from scholarships, grants, traineeships, or Veterans Benefits, etc, from any other source?
*
Yes
No
If yes, please list these sources and amount received:
Describe how course(s) relate to present job or another LBH position:
*
Please identify degree:
*
(ex. AA, BS, BSN, etc.)
Area of Concentration:
*
(ex. Nursing, Business, etc.)
Reimbursement in Calendar Year:
*
Expected Graduation:
*
/
Month
/
Day
Year
Date
Typed Name:
*
Signature:
*
Date/Time:
Submit
Submit
Should be Empty: