Name:
Payroll
Number:
Address:
Phone number:
Providing an e-mail address
allows us to e-mail you ICD
updates.
E-mail address:
Department:
Position title:
School or Institution to attend
:
Address
:
Web link:
What best describes your educational goal:
Certificate
Bachelor Degree
Continuing
Education
Associate Degree
Graduate Degree
Other - Describe
Other
Semester begins on:
Semester ends on:
Course name:
Books*
Fees*
Tuition
Costs:
Total Costs:
*
Do not include non-mandated books, equipment or other non-tuition costs.
By submitting this form I agree that:
I am not receiving duplicate tuition
assistance
from any other sources.
When I finish my studies I will send proof of
completion to the Learning
Center if
applicable.
I authorize the Institution listed above to
release any information requested
by UPI
Career Development regarding tuition paid,
benefits or scholarship
aid received, or
completion of courses.
In addition to this application you must
submit all supporting documentation by mail
or in person to:
Jessica Carpio
900 Loveridge Road
Pittsburg, CA 94565
MS17
Supporting documentation for "Tuition
Reimbursement" includes the following:
Complete address and or web link to the
instution/school; copy of course description
from the institution/school catalog; copy of
proposed tuition costs along with
compulsory fees (lab fees, material fees).
Initial:
Date:
Printable
Form
Active Employee
Application for Tuition Reimbursement
ICD
