TUITION REIMBURSEMENT FORM
2-1-19
1. Upon successful completion of a course (at a regionally-accredited or CHEA-recognized institution other than EFSC), forward a
completed and signed Tuition Reimbursement Form for each course, proof of tuition cost and payment, and a grade report either
by email to Tuition@easternflorida.edu or by campus mail to the HR/Tuition Program Office on Cocoa Campus.
2. The reimbursement request must be received within 30 (thirty) working days after completion of the class.
HR
Date Received:
HR Initial
AVP Initial:
HR Notes:
Instructions to Accounting Amount to reimburse: $ __________________
on
Name: Date:
Term:
Employee B number: B
Office Phone: Date of Hire:
Job
Type
Job Category (choose most appropriate):
Full-time employee, non-faculty
Regular part-time employee, non-faculty
Full-time faculty
Part-time (adjunct) faculty
PT
If PT Faculty, mark your selection for the following:
Length of time teaching (select one):
6+ semester hours during previous academic year
Less than 6 semester hours/previous academic year
T
eaching Schedule (select one):
Teaching at EFSC during time of course completion
Not teaching at EFSC during time of course completion
Name of Accredited Institution:
Number of Credit Hours: 1, 2, 3, 4, 5+
Course ID Number:
Number of times taking course: 1, 2, 3, 4+
Course Objective (choose most appropriate):
Associate Degree Master’s Degree
Bachelor Degree Doctorate Maintain Certification
I
ndicate tuition total: $
Aid
Are you receiving any type of financial aid? Yes No If you are receiving financial aid what type?
Scholarship Un-sub (Stafford)
Grant Sub (Stafford) Other
If you are receiving financial aid and selected “Other” for financial aid type, please describe:
Indicate whether you are submitting items required for HR review prior to reimbursement:
Copy of institutional receipts for tuition and proof of payment (hard copy or electronic copy) with institutional identification included on
paperwork.
Copy of grade report (hard copy or electronic copy) with institutional identification included on paperwork.
Ineligible
Reimbursement is NOT available for:
• Classes taken at EFSC (tuition waiver is available);
• Classes marked as dropped, withdrawn, or incomplete;
• More than one attempt per course;
• Course fees and expenses;
• Classes with an earned grade of less than C- for undergraduate work or less than B- for graduate work;
• Classes for which previous reimbursement, scholarship, or grant funding was received;
• Classes taken while employee was participating in the Professional Leave with Pay program;
• Submissions not received in HR within 30 (thirty) working days of class completion.
Check each box to indicate your understanding and agreement (all boxes must be checked):
I certify that the information given above for tuition reimbursement is true and correct.
I understand that the College reserves the right to withhold reimbursements when select balances are owed to the College by the
employee.
Signature as agreement to above information: ___________________________________________________________
click to sign
signature
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