U. W. Madison
Request for Authorization to Reimburse Employee Tuition

(See Personnel Policies and Procedures Handbook, Chapter 12.01.)

  Unclassified Staff
Non-Represented Classified
Represented Classified Staff
     Bargaining Unit

TO BE COMPLETED BY EMPLOYEE:
EMPLOYEE NAME: CLASSIFICATION:
(Official Budget Title)
DIVISION/COLLEGE: DEPARTMENT:
YEARS OF SERVICE
IN WORK UNIT:
WORK SHIFT HOURS:
HIGHEST DEGREE HELD: MAJOR:

Proposed Course of Study:
Course Title:  
Course(s) Number:  

Have you been admitted?       Undergraduate      Graduate      Special
             UW-Madison      UW-EXT      MATC      Other
Semester offered: Number of credits: Total fee and tuition:

When is/are the course/s offered?

What is the relationship between the course/s you want to take and your present position?

Have you been reimbursed for training before? Cite dates and study undertaken:

EMPLOYEE SIGNATURE__________________________________ Date:______________

Note: In order to be eligible for reimbursement, an employee must continue employment in state service after successful course completion.

(Second side to be completed by supervisor/chair/director or dean/director.)
**PERSONNEL OFFICE USE ONLY**
Employee Training/development (3160)
Employee Education (3161)
Graduate Level Course Work (3163)
**For Pre-audit Use Only**
Fee/Instruction cost:____________

Segregated Fees:____________