[Firm Name]

Tuition Assistance Program

Reimbursement Agreement

This Tuition Assistance Program agreement requests pre-approval of the education expenses pertaining to my studies and consists solely of tuition and textbook costs to be incurred by me.   Approved expenses will be reimbursed over and above grants and scholarships received in the same time period.

Employee Name:                                                                .

[Firm Name] Tuition Assistance Program Approval Request

I hereby request approval for tuition and textbook costs up to $1,500 per year related to the following courses:

(Please list courses, tuition, approximate book costs and expected dates and time of attendance.  If courses are being taken to earn a degree or certification or if the duration of the entire program will be over 12 months, please list details of the entire program)

The benefit of my taking each course, earning the degree or earning the certification is as follows:

Employee Signature                                                                    Date                                                                .

Approval of PIC                                                               .           Date                                                                .

Forward original approved copy immediately to HR for filing in personnel file.  Keep a copy to attach to request for reimbursement.