Broward County Public Schools Tuition Reimbursement
Form
Name: __________________________________________
Location Number: __________
SSN#: _________________________________
Location Name: ____________________________________________
Critical Shortage Area: _________________________________________________________
University Attending: _______________________________________
Term: _______________________
Course #
Course Name
Grade
Tuition Amount
_________________
__________________________
_________________
_________________
_________________
__________________________
_________________
_________________
_________________
__________________________
_________________
_________________
TO BE COMPLETED BY THE UNIVERSITY
This certifies that the above listed teacher has paid the total amount of $________________ for _____________ graduate/undergraduate course
hours at _______________________ (name of institution) for the _________________ term.
Signed by: _____________________________________________
Title: _________________________________________________
INSTRUCTIONAL STAFFING OFFICE USE ONLY
Approved amount $______________________
Approved by ____________________________
Date: ______________________