Educational Assistance Program Request Form

RMI EDUCATIONAL ASSISTANCE PROGRAM REQUEST FORM

Employee: ___________________________________________Job Title:_____________________________________________

Daytime Phone Number: (____)________________________Email Address: _______________________________________

Work-site Employer: __________________________________Employee Status:

Full-time Part-time

Work-Related Course: _________________________________Dates of Course: _____________________________________

Technical College

Name of Accredited School: ____________________________________________

Two-year College

Name of Accredited School: ____________________________________________

Four-year College/University Name of Accredited School: ____________________________________________

Employee Signature: ____________________________________________________Date: ______________________________

Work-site Employer Name Printed: __________________________________________________________________________

Work-site Employer Signature: __________________________________________Date: ______________________________

Please submit your completed form to your assigned RMI HR Specialist PRIOR to beginning your course. Course must be pre-approved. This form will be returned to you indicating an approval or denial. Upon completion of your work-related course, you must submit to your assigned RMI HR Specialist proof of payment and report card/transcript showing a grade of at least a "B" or better, pass/fail, or certificate of completion in order to be reimbursed.

Educational Assistance is:

Approved Denied because:

Not employed with RMI for one year Not a full-time employee Course not work-related Maximum benefit reached

Course not pre-approved by work-site employer Course not taken at an accredited school Course taken before completing one year of full-time

employment

________________________________________________________ RMI HR Specialist Signature

____________________________________ Date

For RMI Internal Use Only:

School Accreditation Confirmed:

Confirmed

Not Accredited

PEO Hire Date: ______________________________________________________Employment Status:

Full-time

Part-time

Course Taken After Completing One Year:

Yes No Amt. Paid in Current Year: $_______________________________________________

Notes:___________________________________________________________________________________________________________________________________

Total Amount Paid-to-Date: $__________________________________________Amount to be Reimbursed for this Course: $_________________________

Proof of Payment and Report Card, Transcript or Certificate of Completion is attached indicating a grade of at least a "B" or pass.

Department

Approved

Signature

HR Specialist _______________________________

_____/_____/_____

_______________________________________________________

HR Director ________________________________

_____/_____/_____

_______________________________________________________

Finance ____________________________________

_____/_____/_____

_______________________________________________________

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