Please complete this form and submit it to:
Please complete this form and MAIL to: Maine Apprenticeship
55 State House Station
Augusta, ME 04333-0055
Please be sure to attach copies of the following:
Ø Copy of your grade report (or other proof) showing you successfully completed the course(s) with a C or better
Ø Copy of the bill from the college or institution at which you took the course(s)
Ø Copy of receipt (or other proof) showing course tuition has been paid in full and by whom it was paid
Ø FOR UMO Apprentices only: Provide verification of hours worked from the Student Employment office for semester in which tuition reimbursement is requested
NOTE: Tuition reimbursements are to be paid to the entity that paid the course bill. If your employer has paid tuition on your behalf, be sure they have submitted a Vendor Form. Reimbursement checks cannot be issued without a current Vendor Form. If you have a change of address you must submit a new Vendor Form in order to receive reimbursement.
PROGRAM INFO: By person or business requesting reimbursement
| |
|Apprentice Name: _____________________________________ ID# or SSN#:__________________________ |
| |
|Program of Study:______________________________________ Ph1:________________Ph2:________________ |
| |
|Email Address: ______________________________________________________________________________ |
| |
|Course Information: Circle Semester SPRING FALL SUMMER |
|1) |
|Course Title: _______________________________________________ Course Number:_____________ |
| |
|Grade:____ # Credits:_____ College or Institution:___________________________________________ |
| |
|Course taken from: ________/_____ to: ________/_____ Tuition Cost*: $_____________________ |
|month year month year *MAP reimbursement is not for fees, books, etc. |
|2) |
|Course Title: _______________________________________________ Course Number:_____________ |
| |
|Grade: _____ # Credits: _____ College or Institution:__________________________________________ |
| |
|Course taken from: ________/____ to: ________/____ Tuition Cost*: $______________________ |
|month year month year *MAP reimbursement is not for fees, books, etc. |
| |
| |
|Apprentice Signature:______________________________ Date:____________________________ |
|PAYMENT INFO: Office Use Only |
| |
| |
|PAY TO: __________________________________________________________ VC#: ____________________________________________ |
| |
| |
|ADDRESS: _________________________________________________________________________________________________________ |
| |
|FUND |DEPT |UNIT |SUB U |OBJ |TASK |TASK ORDER |
|010 |12A |B125 |01 |6510 |B125 |23110 |
Revised 7/10
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