EMPLOYER TUITION REIMBURSEMENT AGREEMENT
Student Name______________________________ Student ID#________________________
Semester___________________________
Course #(s) and Title(s)__________________________________________________________
_____________________________________________________________________________
STUDENT CERTIFICATION
Partial Reimbursement
100% Reimbursement
I agree to pay all tuition and fees not covered by my
employer (employer only pays portion of tuition/fees)
I agree to pay a $125 deposit (per semester) towards my
tuition bill (employer pays 100% tuition AND fees)
I agree to the terms and conditions of this employer tuition reimbursement agreement. It is
understood that if I drop or withdraw from a course, I am responsible for the full amount of tuition and
fees in accordance with the published Refund Policy. I am responsible for printing a copy of my final
grades and submitting the grades to my employer for payment processing.
In exchange for deferring my tuition and applicable fees until my grades are available, I authorize
Edinboro University to charge my credit card for my unpaid balance if the semester invoice is not paid
within 60 days after the conclusion of the semester. I understand this card will not to be used to
pay my portion of the bill or the deposit in order to defer the balance at start of semester.
Credit Card type:
MasterCard
Visa
Discover
Card Number _______-________-________-________
Exp. Date_____________
CSV# ________________
Student Signature_____________________________________ Date__________________
*Please send the completed Tuition Reimbursement Agreement with all applicable payments/deposits to the
Bursar’s Office by the due date shown on the semester invoice. Failure to provide credit card information will
nullify this Agreement – all account balances will become payable by the due date. A new Tuition
Reimbursement Agreement must be completed each semester.
EMPLOYER CERTIFICATION
Amount of tuition authorized: $_________/credit or ______% of tuition
Amount of fees authorized: $_________, All or None
Employer will pay:
Employee/Student
Edinboro University
Employer Name/Address_________________________________________________________
_______________________________________________________
_______________________________________________________
Contact Name______________________________ Phone Number______________________
The Employer agrees to pay the amounts shown above on receipt of the employee/student’s final
grades for the course(s) taken.
Employer Authorized Signature_________________________________ Date_____________
Bursar/Templates 2011