Form copy

APPLICATION FOR TUITION REIMBURSEMENT FOR PROFESSIONAL DEVELOPMENT
AS PROVIDED IN ARTICLE 23 OF THE CERTIFICATED AGREEMENT
NOTE: 1) Complete one application per semester, quarter, seminar, workshop, etc.
2) This is to be submitted no earlier than 30 days prior to the date that the course (s)
start and no later than the end of the second week of classes.
Name of Member of Certificated Unit
Employee #
City
Home Address
Campus/Worksite
Acting/Regular
Present Position Title
Date
Extension
Department
Teaching Discipline
Zip
1) I request approval for reimbursement of tuition that will be paid for the following workshops, institue or courses to be completed at:
Location of Campus Where Classes Will Meet
Name of Accredited Institution
Subject
2) Present Assignment: Full Time
Course
No.
Units
Title
No.
Start Date
Total
Total Reimbursement*
Part Time
Teaching
Hours
Title
Amount of Tuition
End Date
*50% of tuition paid to a maximum of $3,000
per fiscal year.
(See Personnal Guide B560)
FOR OFFICE USE ONLY
ENCUMBRANCE
Total Teaching Hours
3) If not teaching, describe how the proposed professional development
program is related to the non-teaching assignment.
This is to certify that I have not or
will not receive funds from the LACCD
in excess of 100% of the cost of this
activity.
Applicant’s Signature
Committe on
ACKNOWLEDGED BY: Tuition Reimbursement
Pres. or Div. Head
Signature
FISCAL YEAR
Applicant’s Class
Unit
Approved
Disapproved
Date
LOC.
FUND/PROG
OBJECT
ACTIVITY
AMOUNT $
DATE
Action
INITIAL
APPROVED DISAPPROVED
REASON: