EMPLOYEE TUITION REIMBURSEMENT PROGRAM

Terms of Agreement
  1. I am submitting my completed Tuition Reimbursement Request Form to NHRMC Human Resources prior to the beginning of class or certification exam. I understand that applications submitted after the course start date or exam date will be denied.
  2. I understand NHRMC will not advance for books. I will only be reimbursed for books after they have been purchased. To receive book reimbursement, I will submit a paid receipt with textbook title and a copy of the syllabus to show that the books are required for my courses. Book receipts can be submitted after the Tuition Reimbursement Request Form.
  3. My Tuition Reimbursement Request Form is for tuition, books and initial certification exams only. I have included all fields on the form. I understand the certification exam dates can be an estimated date, but must be included. I will provide HR with the exact date when I receive it.
  4. My Tuition Reimbursement Request Form is not for expenses for which additional educational benefits are available such as Veterans Administration, grants, scholarships, etc. I have disclosed all additional educational benefits I will be receiving.
  5. I understand I must receive a C or better (B or better for graduate courses) or a P grade for Pass/Fail courses or certifications. If I receive and advance I must submit my official grades within 30 days of the course completion.
  6. I will maintain an active 0.5 to 1.0 FTE status through completion of the course or pass the initial certification exam to qualify.
  7. I understand the reimbursement will be credited to the calendar year in which the class ends, up to $2000 per calendar year.
  8. If I terminate employment with NHRMC for any reason within 24 months of the paycheck date in which funds were received I will repay NHRMC in accordance with a pro-rated formula as follows: A) The full amount of tuition reimbursement paid to me in any of the 12 months preceding termination and/or; B) ½ the full amount of tuition reimbursement paid to me in any of the 13 – 24 month period.
  9. If I do not successfully complete the course/exam I will immediately notify HR. I understand I will not be eligible for additional tuition assistance until the initial advancement has been repaid in full which will be collected immediately and in full via payroll deduction.
  10. I have successfully completed my 90 day trial period.
  11. My status is active and at least 0.5 FTE
  12. I have not received any written disciplinary actions in the past year.

I have read the terms of agreement and agree to abide by all of the terms listed above.

Signature & Date

Print Name

EMPLOYEE TUITON REIMBURSEMENT APPLICATION

Employee Number(required) / Last Name / First Name / MI
Date of Hire / Daytime Phone Number / Work Email Address

Degree or certification pursuing:

/ Major (if applicable):
Department Name & Number / Job Title / Manager/Director

School Attending

Course Number and Title or Initial Exam

/ Start Date / End Date / Credit Hours / Cost per credit hour / Tuition or Exam Cost (do not include any additional fees) / Required Textbook
(provide syllabus and receipt) / Cost of Books (do not include shipping or tax)
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
Totals Credits / Total Tuition / $ / Book Total: / $
I would like to have the funds reimbursed to me: Prior to the start of the course After I submit to my grades
Amount of grant or scholarship money received: $
Total Amount Requested for Tuition and Books (not to exceed $2,000 in this calendar year): $

APPLICATION DIRECTIONS

  • To receive your tuition assistance money, mail or fax (910-815-5969) this form and required documentation(schedule and invoice)to HR Benefits. Reimbursements will be processed based on the supporting documentation. Incomplete supporting documentation will reduce or deny your reimbursement.
  • Your reimbursement is processed within 30 days of receiving complete documentation. You will be notified via your work email.
  • If you received an advance, submit your official grades and proof of payment within 30 days of the course completion.
  • If your grades are not received in 30 days of the course end date, or you fail or withdraw from your courses or exam your full advance will be recouped from the next paycheck.
  • If the fields are left blank or you fail to include supporting documentation, your reimbursement will be delayed or denied.
  • Reimbursements for approved applications will be added to the employees’ regular paycheck by direct deposit. You will receive a confirmation email once your application is processed. Incomplete documentation will result in a delay or denial of your reimbursement.