Winston-Salem/Forsyth County Schools
Exceptional Children
CDL Reimbursement Application
Name:
(Last) (First) (Middle)
Social Security Number:
School Assignment (s):
Teacher/Assistant:
Subject Area:
I currently hold a valid NC Driver’s License #______.
I am submitting original receipts for coursework and licenses that is required to fulfill the conditions of my CDL license. A copy of my CDL is attached. I understand that by signing below and submitting this documentation, I am agreeing to continue to teach in my EC license area for Winston-Salem/Forsyth County Schools for TWO years until the end of the 2018-2019 school year or repay tuition reimbursement amount.
Signature Date
NOTE: State auditing regulations require that you submit original receipts detailing billing charges by category and indicating that you have made payment. Internet receipts must include your name, school name with emblem and the amount of your payment, and an itemized list of charges.
Please return this form to Matt Dixson c/o Joette Unks in Human Resources no later than 4:30 PM on Thursday, May 12, 2016.
Winston-Salem/Forsyth County Schools
EC Employees 2015-2016 CDL Tuition Reimbursement Application
(for coursework completed between January 2016 and May 2016)
PLEASE TYPE OR PRINT Please make additional copies as needed.
Name:
Last First Middle/Maiden
School/Location: Social Security #:
Current Assigned Role:
EC Experience:
Years (from-to) School/Department (include city/state) Assigned Role
Your Reason(s) for Enrolling in Course(s) – please check all that apply:
o to meet CDL requirements for transporting students required for my position
r required by supervisor to meet school needs
o other (state reason)
I am applying for a CDL Reimbursement Scholarship for these course(s) or fees:
Beginning/Ending
Course Title and Number Location Dates of Courses Cost**
$
$
Page 2
**Cost for course only - exclude activity and other fees associated with the course(s)
ORIGINAL RECEIPTS* OR CANCELLED CHECKS MUST BE ATTACHED
*Receipts must have school name, your name and amount PAID – NOT AMOUNT DUE!! School or University website with emblem will be considered original if paying on-line.
How will the course(s) address your professional career goals and our school system goals?
Comments/Recommendation of Your Supervisor:
Signature Date
Scholarship Applicant
Signature Date
Supervisor
Application Deadline: 4:30 PM on Thursday, May 12, 2016
Note: Forms received without ORIGINAL RECEIPTS OR CANCELLED CHECKS will be returned and WILL NOT be eligible for further consideration. Internet receipts must include name, school name with emblem and social security number and payment made. Forms must be complete with signature and received before the deadline for consideration. Please submit your completed application to Matt Dixson c/o Joette Unks in Human Resources. Telephone: 336-748-4079.