Tuition Reimbursement Form

Employee Name

Payee ID

Payroll Job Title

Division

Unit/Dep't

Phone 1 () -

Phone 2 (optional) () -

E-mail

Educational Institution

Field of Study

Intended certification or degree:

Course Name(s) (separated by commas)

Cost of Tuition/Fees
(Reimbursement amount requested, round up to whole dollars)
$

How will this course(s) relate to your current or prospective duties? (400 char max)

How is this course(s) related to a larger degree, certificate or program? (400 char max)

Do you intend to apply for reimbursement of additional courses in the future? Yes No

Acknowledgements

I certify the university I am attending is a public technical institute, public junior college, public senior college or university, or public state college. (Visit the National Center for Education Statistics to see if your school qualifies as "public".)

I certify that I am attending classes between the application acceptance period, provided in attachment A of the Tuition Reimbursement Policy, AD-11.78.

I agree to remain employed with TDCJ during the course(s) and for an amount of time after completing the course(s) equal to one month for each month of the reimbursed course. I understand that reimbursement for tuition expenses will not be provided if I fail to remain employed with the TDCJ for the required time after completing the course(s) and reimbursement has not yet been provided. I understand that I will be required to repay the agency an amount equal to the amount previously reimbursed for the semester if I fail to remain employed with the TDCJ for the required time after completing the course(s) and reimbursement has already been provided to me.

Text Check: leave this field blank:

Tuition Reimbursement

Application Form