Individual Course Reimbursement Form

MECKLENBURG COUNTY PUBLIC SCHOOLS
Master's Reimbursement Program

Individual Course Reimbursement Form

I plan to enroll in the course listed below and seek reimbursement through my approved Master's Program.

* Name of Course:

* Course Number:

Course Dates:

* Starting Date

* Ending Date:

* College/University:

* Tuition Amount Due:

In order to receive reimbursement, I understand that the following items must be attached.

* 1. Grade Report or evidence of grade of A or B attached
(must be an official report distributed by the college/university)

2. Receipt showing amount of tuition paid to the college/university
(must be a receipt showing the amount paid - not the amount due)

* Social Security Number:

* Base School:

* Employee Signature:

* Date:

Typing your name in the space above serves as your signature.

* Home Address:

Do not Complete the Information Below:
Central Office Department of Instruction Use Only

Cost Code Number:

Amount to be reimbursed:

Signature of Cost Code Administrator:

Date:

* Indicates Response Required