Nottoway County Public Schools

NOTTOWAY COUNTY PUBLIC SCHOOLS

TUITION REIMBURSEMENT REQUEST

Please submit this completed form to the Director of Staff Development two weeks prior to enrolling in a course for which reimbursement is requested. The immediate supervisor’s recommendation is required. A grade report and receipt of payment must be received by the Director of Staff Development upon completion of the course before reimbursement will be made. Staff members applying for reimbursement must be certain the stated reason(s) for taking the class reflect(s) the mission of the school system.

A. EMPLOYEE INFORMATION

Social Security Number / Name______
(Last) (First) (Middle/Maiden)
Mailing Address
______
(Street) (City) (State) (Zip Code)
Home Phone / School Name / Position

B. COURSE DATA

College or University / Department
Course Number / Course Title / Instructor
Credit Hours Received
______Semester Hours ______Quarter Hours
______None / Actual Tuition Rate: $______
Approved Rate of $______
Reimbursement
For Classes Beginning
 Fall  Winter  Spring  Summer Year______
Reason for Enrolling in Class:______
______

C. SIGNATURES

______
Registrant Date
______
Supervisor’s Signature Date
______
Director of Staff Development Date

Memorandum of Agreement

If for any reason you are no longer employed by Nottoway County Public Schools within three calendar years of completing any class, you will be required to reimburse the Nottoway County School Board a prorated amount of the total reimbursement for all the classes. Payment will be made to the Nottoway County Public Schools by the end of the fiscal year in which employment is served. The repayment of all reimbursements received for all degreed program classes shall be:

• 100% if resignation occurs within one year from the date of the last class completed.
• 65% if resignation occurs within two years from the date of the last class completed
• 33% if resignation occurs within three years from the date of the last class completed.

Involuntary separation, death, or total disability will negate the repayment clause.
I acknowledge that if the terms of this agreement are not fulfilled, I must reimburse Nottoway County Public Schools.
By signature at the bottom of this agreement, I agree to the arrangements and terms set forth.
______
Signature of Employee/Registrant Date

For Staff Development Use Only

 Request granted $______Amount Approved
(Contingent upon verification of amount of tuition paid and reimbursement funds used.)
 Request denied
Reason: ______
______
Director of Staff Development Date