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Professional Development Tuition Reimbursement
Application and Approval Form
PART I: APPLICATION_______________________________________________________________
CNM ID#
Employee Name
Department
Ext:
Employment Status
Institution Name
Year: Choose
an Yeear
choose year
Term
_______________________________ Program Type
Course Title
Course Number
Credit Hours
choose term
choose program
Course Start Date
End Date
Please sub
bmit a class scchedule with your application
Employee and Dean/Supervisor Signature Required
Employee Signature: _________________________________
Date ____________________________
Dean or Supervisor Approval ____________________________ Date ____________________________
PART II: CERTIFICATE OF COMPLETION________________________________________________
Received By
__________________________________
Approved and On File___________________________
Date _____________
Credit Hours
____________________________________
_____________
Date ________________
Dean/Supervisor signature
PART III: TUITION REIMBURSEMENT APPROVAL_________________________________________
Amount meeting requirements for Employee Tuition Reimbursement
Cost Account_____________________________________
$_______________
ID Number _________________
Date ___________
Approval for Payment authorized by Dean/Supervisor ________________________________________________________
___________________________________________________________________________________________________
Distribution: Original to Business Office; other copies to applicant and Dean/Supervisor
Updated 10.23.2015