Educational Assistance Pre-Approval Application

Educational Assistance Pre-Approval Application

This form MUST be completed, submitted and approved PRIOR to the course start date to be considered eligible for reimbursement.

Please note – A separate application form must be submitted for each school/university/institution that you attend.

This application is for one term only. Term is defined by your academic institution (semester, quarter, etc.).

Contact Information – All applicable fields MUST be completed for application processing / Fax Number: 901.748.0469
Employee Name: / Employee ID:
Email Address:
Degree Program: (check one, if applicable) Associates Bachelors Masters Doctorate
Program/Major:______(Must be completed if Degree Program checked)
Course Information - All fields MUST be completed for application processing
I wish to take the following course(s) under the provisions of the CPS Educational Assistance Policy. I certify that these courses will be taken on my own time and I am not receiving money from other sources unless indicated below. I understand that if I violate the terms in the Educational Assistance Policy or do not disclose all sources of funding, I will be disqualified from receiving future reimbursements.
Name of School (No Abbreviations):
Course Code / Course Title / Start Date MM/DD/YYYY / End Date MM/DD/YYYY / Tuition Amount
$
$
$
$
Total Tuition Amount / $
Lab Fees, Computer/Technology Fees and Registration Fees are Eligible.
Non-Eligible Fees Include (but are not limited to):
Student Union Membership, Health Service/Athletic Fees, Late Registration/Deferred Payment Fees, Non-Resident Fees, Equipment Purchases, Books, Materials, and/or Supplies, Parking and/or Transportation Fees / Add Eligible Fees / $
Please indicate any external financial assistance in the form of scholarships, grants, fellowships, veterans, or other subsidies not considered loans requiring repayment. / Less Financial Assistance / - $
Total Adjusted Reimbursement / $

Employee Signature—Please Read Before Signing

I understand that CPS will reimburse for the cost of tuition and required fees for each course only after I have paid for and satisfactorily completed the course. I understand that in order to be reimbursed for the course, I must receive a “Pass” for courses taken on a Pass/Fail basis, a “C” or better for undergraduate courses, and a “B” or better for graduate courses. I will submit my pre-filled Tuition Reimbursement Application, Tuition/Fee Statement, Official Grade Report, and Receipt/Proof of Payment Documentation to Human Resources within ninety days after course completion. I understand that if I voluntarily terminate my employment with CPS prior to the start date of any approved coursework or during an approved period for taking coursework I will not be eligible for reimbursement under the Educational Assistance Program. I understand that if my employment is terminated with CPS prior to the start date of any approved coursework or during an approved period for taking coursework due to disciplinary, performance or other reasons that remove an employee from good standing as determined by management in its sole discretion I will not be eligible for reimbursement under the Educational Assistance Program. I understand that if my employment is terminated with CPS prior to the start date of any approved coursework or during an approved period for taking coursework due to a reduction in workforce or layoff I maynot be eligible for reimbursement under the Educational Assistance Program.

I understand if I fail to complete coursework or obtain the required minimum grade, I will not be reimbursed for the tuition or fees associated with that coursework.

I understand that tuition reimbursement may be subject to all applicable withholding taxes and included as other compensation on my W2 form. I should consult my tax advisor to determine if the course tuition is tax deductible. I understand that I may not receive 100% reimbursement based on current and applicable tax withholding requirements. Note: CPS reserves the right to amend this policy at any time or without notice.

Employee Signature: Date:

Educational Assistance Pre-Approval ApplicationPage 2

Employee Name: Employee ID:

APPROVAL Signatures—All fields MUST be completed for application processing
Manager Approver: Please Read Before Signing.
By signing this application, I hereby acknowledge that the employee meets all eligibility requirements for participation under the CPS Educational Assistance Program.

• Employee is NOT on written warning, probation, or immediate probation.
• Employee must work more than 32 hours per week.
• The degree or coursework is related to employee’s current position OR will prepare the employee for another position within the company.

Manager Approver
Name (Printed): ______
Signature:
______
(Signature indicates Approval) / Email: ______
Title: ______
Date: ______
Second Approver
Name (Printed): ______
Signature:
______
(Signature indicates Approval) / Title: ______
Date: ______
* Third Approver (Corporate approval only)
Name (Printed): ______
Signature:
______
(Signature indicates Approval) / Title: ______
Date: ______

* This approval from Corporate Office – application isn’t approved without this signature.

Educational Assistance Process

Before Taking a Course:

• Discuss plan to participate in the Educational Assistance Program with your manager BEFORE enrolling in coursework. Please explain how this coursework relates to your present job responsibilities and/or would contribute to your career advancement at CPS.

• Complete and sign Educational Assistance Pre-Approval Application BEFORE enrolling in coursework.

• Your manager and the second level approver will then review the Application Form to ensure all eligibility requirements have been met. Second level approver for all business units is the manager’s next level manager.

• After manager and second level approvals are obtained (and third level if required), submit the Pre-Approval Application to Human Resources at (901) 748-0469. (You must submit the Pre-Approval Application prior to the course start date to be eligible. Please note that final approval is given at the corporate office so once application is sent to corporate, the request will be marked approved or denied and returned to the employee at that time.)

After Course Completion:

• To receive tuition reimbursement, fax the Itemized Tuition/Fee Statement, Official Grade Report, and Receipt/Proof of Payment Documentation within thirty days of course completion to Human Resources at (901) 748-0469.