Last Name:

First Name: M.I.

Social Security Number:

Home Address - Street:

City, State, Zip:

E-Mail Address:

Home Department:

Work Telephone:

Faculty or Staff: Faculty Staff

Job Title:

FTE:

Are you a graduate degree student?: Yes No

Academic Year: 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013

Term: Fall Spring Summer

College: Castleton State College Community College of Vermont Johnson State College Lyndon State College Vermont Technical College

Course Title(s), Code(s) & Credits:

Cost of Course(s):

Comments:

By pressing the "Submit" button below, I acknowledge that I understand the conditions of pre-approval and reimbursement, as outlined in the Officers' Handbook and the Staff Handbook. I also understand that graduate-level courses may be subject to taxation. Further, I certify the information supplied is correct to the best of my knowledge, and I hereby request pre-approval for tuition reimbursement.