CT-42a (Revised 6/12)
Please PRINT Clearly or Type
APPLICATION FOR TUITION REIMBURSEMENT
CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM ADMINISTRATORS
Submit this application form to Barbara St. Onge in Central Office at least 2 weeks prior to registration for course work for final review by the
CTHSS PD Consultant, the Assistant Superintendent and the President and Vice President of Administrators Union . After all signatures the
form is then sent to Karen Gliha at DFIO for the final reimbursement processing.
PLEASE PRINT CLEARLY OR TYPE
NAME:
EMPLOYEE ID#:
SCHOOL:
SCHOOL ADDRESS:
INSTITUTION ATTENDING:
Start:
Summer
Check as appropriate:
_____A. Courses to complete Advanced Degree
_____B. Courses to complete Bachelor’s Degree
or System Goals
_____C. Non-Credit course for Professional
Growth
_____D. Graduate course to prepare for new
position
_____E. Courses to achieve 092 certification
_____F. Other:
IMPORTANT: PAYMENT IS
SUBJECT TO AVAILABLE FUNDS.
Be sure to show the cost of EACH
CREDIT as well as the total cost of all
credits in applicable spaces below.
Failure to comply will result in rejection.
Reimbursement is for TUITION
ONLY.
Cost per credit $
COURSE NO.
/
/
Mo/Day/Year

Finish:
Fall

COURSE TITLE
/
/
Mo/Day/Year
Spring

NO. OF CREDITS
The above courses are:

Graduate Courses

Undergraduate Courses

Other
Payment is based on cost per credit at UCONN pursuant to Article 13 in Administrator’s
Contract
x Total # of Credits
=
Cost of Non-Credit Course
Credit Cost $
$
LESS - Financial Aid Received from Other Sources
-
$
(NOT TO EXCEED 12 CREDITS PER FISCAL YEAR)
NET COST $
Describe briefly how the course/s will relate to your professional development objectives and/ or the objectives of Connecticut Technical High School System.
APPLICANT’S CERTIFICATION: I certify that I am familiar with the regulations for tuition reimbursement and will comply with them. I will
notify the Division of Finance and Administrative Services if a course is failed or dropped.
Signed (Applicant):
Date:
Building Principal Recommendation __________________________
YES ____ NO _____
Prof. Dev. Comm. Recommendation __________________________ President
YES ____ NO _____
Prof. Dev. Comm. Recommendation __________________________Vice President YES ____ NO _____
Prof. Dev. Comm. Recommendation __________________________PD Consultant YES ____ NO _____
SYSTEM APPROVAL
Date: _______________
Date: _______________
Date: _______________
Date: _______________
DFIO APPROVAL
(Assistant Superintendent)
No of approved Credits ______________________
AMOUNT TO BE REIMBURSED $
_________
Instructions for Completing Form CT-42a
Application for Tuition Reimbursement -Administrators
The Form CT-42a - Application for Tuition Reimbursement must be submitted to Barbara St.
Onge in Central Office at least two weeks prior to the start of classes. Send this form
along with the completed Form CO-101.
The application must state the cost per credit for the course. Any financial aid received
from other sources, e.g. BEOG, Title XX etc. must be stated. Loans given directly to the
employee that must be repaid need not be reported. If a loan is paid directly to the
educational institution a statement must be submitted with the application explaining that
financial aid is in the form of a loan.
Any changes in course titles, failure or dropping of a course must be reported to the
agency’s officer within 10 days.
The request will be approved and signed by the Building Principal, reviewed for
completeness by Barbara St. Onge, PD Consultant, reviewed and signed by PD Committee
(President and Vice-President of Administrators Union) and forwarded to an Assistant
Superintendent for approval and signature. Once that procedure has been completed,
Barbara St. Onge will send the CO-42a reimbursement request along with the CT-101Admin. directly to Karen Gliha, Division of Fiscal and Internal Operations, (DFIO) State
Office Bldg., Room 309, 165 Capitol Ave., Hartford, CT 06106.
Authorization to participate in the tuition reimbursement program will be sent to each
applicant. All correspondence programs, preparation and self-development programs must
be reviewed by the State Personnel Tuition-Reimbursement Coordinator prior to an
employee beginning the course of study.
At the end of each semester, employees must submit receipt of payment and grade report
or transcript to Karen Gliha. This paperwork must be received by the agency no later than
February 1st for Summer and Fall semester courses and June 1st for Spring courses. All
courses beginning in May or ending after May 31st will be credited toward the next fiscal
year Summer programs and subject to available funds and collective bargaining
agreements.
Payment is based on cost per credit at UCONN pursuant to Article 13 in the Administrator’s
Contract.
2/09