File: GCLA-1School TechnologyDiane L. Wolfe202004-05-05T18:49:00Z2008-04-01T17:59:00Z2008-04-01T17:59:00Z12951682County of Albemarle143197411.0000

APPENDIX C4File: GCLA-1PIEDMONT REGIONAL EDUCATION PROGRAM (PREP)REQUEST FOR TUITION REIMBURSEMENTPlease submit this form to the Executive Director or Designee.Date Request Submitted: _______________Employee’s Name: _________________________________ School: ________________Position or Subject/Grade Level You are Teaching: ______________________________Employee’s Mailing Address: _______________________________________________Employee’s E-Mail Address: ________________________________________________Employee’s Home Phone: __________________________ School Ext.: _____________Title and Course Number of Class for which tuition reimbursement is being requested:________________________________________________________________________College/University Offering Class: ___________________________________________Beginning and Ending Dates of this Class: _____________________________________Graduate or Post-Graduate: ___________Certification/Endorsement: __________

To be completed by the Executive Director or Designee

______ This course is approved for tuition reimbursement.______ This course is

not approved for tuition reimbursement because _____________________________________________________________________________________Date: _______________ Signature of Director/Designee: ___________________

Required:

1. Attach a copy of the grade card for this class (Grade of B or above) Grade: ________2. Attach proof of payment or a copy of the canceled check for the class for which you are requesting reimbursement. (A copy of back and front of check is required. The copy must be legible. Check number _______ is attached. If a credit card receipt is sent, please mark through credit card number. Date: ______________ Employee Signature: _________________________________Date: ______________ Executive Director/Designee Signature: __________________