Select OneLACCDOELACLAHCLAMCPIERCELASCLATTCLAVCWLAC
______/ ______/ ______
.
Home Address / City / State / Zip
______/ ______/ _____ / ______
Employee Unit / Acting / Regular / Email Address
Select UnitAcademic Supervisor [Teamsters, Local 911]Building/Trades (Crafts)Maintenance/Operations [SEIU, Local 99]Classified Supervisor [ SEIU, Local 721]Technical/Clerical [Staff Guild, AFT Local 1521A]Management [Unrepresented]Confidential [Unrepresented]
______/ Full Time / Part Time / ______
Office/Work Location / Current Position / Extension / If acting or on leave, from what position?
______/ ______/ ______/ ______
I request approval for reimbursement of tuition that will be paid for the following workshop, conference, institute, or course(s) to be completed at:
______/ ______
Name of Accredited Institution or Entity Offering Conference / Location where classes/conference will meet
Subject / Number / Title / Units / Start Date / End Date / Amount of Tuition
$
$
$
Total / $
Total Reimbursement* / $
List duties in current assignment. / 50% of tuition, textbooks and materials will be paid to a maximum
of Select One$2,000: Academic Supervisor [Local 911]$1,000: Building/Trades (Crafts)$2,000: Classified Supervisor [Local 721]$1,000: Maintenance/Operations [Local 99]$3,000: Technical/Clerical [Local 1521A]$2,000: Management [Unrepresented]$2,000: Confidential [Unrepresented] per fiscal year.
100% of tuition paid if classes taken in LACCD.
For more detailed information about the tuition reimbursement process, see HR Guide R-501, Tuition Reimbursement:
Approved / Disapproved
Describe how the proposed professional development program related to the current classification/position.
Committee on Tuition Reimbursement
______
Member Signature
Reason:
Describe how the proposed professional development program is related to promotional opportunities or career ladder, or will result in more effective administrative service to the District.
FOR OFFICE USE ONLY
ENCUMBRANCE
This is to certify that I have not or will not receive funds from the LACCD in excess of 100% of the costs of this activity. / FISCAL YEAR ______/ AMOUNT ______
CLASS CODE ______/ DATE ______
______
Applicant Signature / UNIT ______/ INITIALS ______
Acknowledged by [Required for Unit 1 only] / RECORDED ______/ WAITLIST ______
______
President or Division Head
LACCD Form HR R-501A 10/18/10 st