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2. Date
   Date
4. Name*
6. Department*
8. Instructions*

   1. 1. Attach an itemized receipt showing the amount of tuition and fees paid by the employee.
   2. 2. Attach official grade report, transcript or certification of completion from educational institution.
   3. 3. Fill out information below and submit.
   4. 4. Submit to HR within 45 calendar days after completion of course.
10. List course for which tuition reimbursement is requested:
12. Course Title
13. Course No.
15. Final Grade
    -- Select One --ABCOther*
16. Other*
    If grade is other than A,B,C,D, F, please explain.
18. Semester and Year
19. Tuition Requested
20. Fees Requested
21. Total Requested
23. Course Title
24. Course No.
26. Final Grade
    -- Select One --ABCOther*
27. Other*
    If grade is other than A,B,C, please explain.
29. Semester and Year
30. Tuition Requested
31. Fees Requested
32. Total Requested
34. Course Title
35. Course No.
37. Final Grade
    -- Select One --ABCOther*
38. Other*
    If grade is other than A,B,C, please explain
40. Semester and Year
41. Tuition Requested
42. Fees Requested
43. Total Requested
45. Acknowledgement*

    1. Agree
    2. Disagree

    I have read and understand the Town's Tuition Reimbursement Policy. I agree that I will remain employed with the Town of Frederick for a minimum of two years after the completion of the above classes. If I voluntarily leave employment with the Town prior to this obligation being met, I will reimburse the Town the full amount of assistance receive. I expressly authorize the Town of Frederick to deduct any amount due to the Town from any Paycheck(s) including but not limited to my final paycheck, in accordance with state and federal law.
47. Submit to:
    -- Select One --Matt LeCerfMegan WilliamsJennifer SimmonsMitzi McCoyDick LefflerGary BarbourRory Hale
49. Human Resources Notification
    Supervisors: Once approved, please make sure to forward response to the Human Resources Director. LMueller@frederickco.gov
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit Submit and Print

* indicates a required field