SEA Tuition Reimbursement Form

Stamford Education Association

Request for Tuition Reimbursement Funds

Please review the guidelines here.

Teacher Name*

Employee ID #

Last five digits from paystub

School *

Teacher City Email Address*

Semester*

Per Article 20F of the contract, I hereby apply for tuition reimbursement for the graduate course(s) listed below. These credits were granted by an accredited college or university. Please include the following attachments to the Human Resources Department via the upload links below:

Proof of Grades - print out from college/university website

Proof of Payment - copy of canceled check, credit card receipt, evidence of student loan or print out from college/university website

(Your request will not be processed until proof of grades and payment are received)

Note: Limited to Nine (9) credits per fiscal year (Summer, Fall & Spring Semesters)

Course Number*

Course Title*

University/ College*

Class Begin Date *

Class End Date*

Credits *

Tuition* $

Do you have another class to submit? *

Yes No

Course Number (2)

Course Title (2)

University/ College (2)

Class Begin Date (2)*

Class End Date (2)*

Credits (2)

Tuition (2) $

Do you have a third class to submit?

Yes No

Course Number (3)

Course Title (3)

University/ College (3)

Class Begin Date (3)*

Class End Date (3)*

Credits (3)

Tuition (3) $

Check the box that applies: *

1/2 tuition for graduate course beyond Master's - $225 per credit maximum 1/3 tuition for graduate course beyond the BA to BA +15 - $150 per credit maximum 1/3 tuition for graduate course beyond the BA +15 to MA - $150 per credit maximum

Description Area

Proof of Grades

No File Chosen

File uploads may not work on some mobile devices.

Proof of Payment

No File Chosen

File uploads may not work on some mobile devices.

Do you have any additional documents you need to upload?

Yes No

Additional Supporting Documents

No File Chosen

File uploads may not work on some mobile devices.

Additional Supporting Documents

No File Chosen

File uploads may not work on some mobile devices.

Employee Signature*

[clear]

Use your mouse or finger to draw your signature above

Today's Date

Human Resource Department

HR Funds Approval *

Denial Explanation

Approved Reimbursement Amount * $

Approval notes

ie. date to expect check by...

Processed by...*

Date Approved

Today's Date