Application
For Tuition Reimbursement
THIS FORM MUST BE SUBMITTED WITHIN 30 DAYS OF START OF YOUR CLASS. PLEASE READ POLICES AND PROCEDURES BEFORE FILLING OUT FORM.

SECTION 1 - PERSONAL INFORMATION
*Name *Employee #
*Email
*Department/Nursing Unit *Job Title *Mailbox # *Cost Center *Indicate Site
MMH Corp OL MP
*Home Telephone # *Work Telephone # *Indicate Status ** If Part-Time - # Hrs Scheduled Bi-Weekly
FT PT**
*Name of School/Location Will you be completing your degree this semester?
YES NO
  If not, expected date of completion
 
SECTION 2 - PROPOSED COURSES
*Course Title *Semester Or Program Dates *Credits *Tuition *Lab Fees Only
From
MM-DD-YY		 To
MM-DD-YY
Name of Degree :
Non-degree course (requires Manager signature)**
Indicate type of degree:
Assoc. Bachelor's Master's
PhD Other
TOTALS =
SECTION 3 - QUESTIONS SECTION 4 - SIGNATURE
Have you ever applied for tuition reimbursement from Atlantic Health?
I hereby apply for tuition reimbursement for the courses listed above. I have read and agree to abide by the policies and procedures governing the tuition reimbursement program described in the instructions. I have disclosed all other financial assistance.
*Emplooyee Signature *Date
   
**I certify that the above non-degree course is recommended for their current job.
Department Head Signature Date
YES NO
Are you receiving any scholarship, grant, G.I. Bill, etc. for this semester?
YES* NO
*If Yes, indicate amount and type of aid other than loan.
Amount: $ Type:



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