Revised August 1, 2015
Pittsylvania County Schools
Tuition Request/Reimbursement Form for
Teachers and/or Administrators
Pittsylvania County Schools will no longer submit tuition payments directly to the college or university. Tuition costs
will only be provided as a reimbursement payment to the teacher and/or administrator requesting the assistance.
The request for reimbursement must be received no later than June 1 of the current school year. If the request IS NOT
received by this date, the approval of payment will become null and void.
Please complete and submit your request for funding prior to registration of a class.
Employee Name (Last, First MI)
Home Address (Required)
SSN
City
State
Zip Code
Term (check appropriate boxes and fill in blanks)
 Fall
 Spring
 Summer
Email Address
Course Start Date and End Date
List College or University
Course Title
Telephone Number
Please Circle Your Current Type of License
Collegiate Professional Postgraduate Professional Technical Professional
Provisional Pupil Personnel
Current Assignment
XXX-XX-_______
Course #
Today’s Date
Base School
Credits
Days (e.g., MWF)
Classroom  Yes
Via Web
Yes
Times (e.g. 2-4)
Cost:
 No
No
If funding is available, amount will be approved for one course at 100% up to $500 per semester.
Please Check the Appropriate Box:
 I wish to apply for tuition reimbursement, not to exceed the cost of tuition per class, in the amount of $_____________
for the course listed above.
 I wish to request reimbursement of fees for successful Praxis II Assessment for an
additional endorsement
Must submit receipt of scores and payment.
(List Area)
online
Tuition Reimbursement excludes the cost of books, e-Books, registration fees, comprehensive fees, student activity fees, resource fees,
fees, online fees, and capital outlay fees.
Employee Signature________________________________________
Date___________________________
PLEASE SUBMIT ORIGINAL FORM OR FAX TO (434) 432-9560
TO THE ATTENTION OF MONICA T. GLASS AT THE SCHOOL BOARD OFFICE
For the Department of Administration Use ONLY
 This application is approved for $
for the course listed above. Please return copy of this form with tuition
payment receipt, documentation of course completion and passing grade to receive tuition reimbursement up to a maximum of
$500.00. Your reimbursement check will be mailed to your home address.
Funding Source:
 Tuition Assistance

Eisenhower
 This application for funding is denied. Reason(s) listed below:
□ Course is not in endorsement area. □ Funding is depleted for the current fiscal year.
Signature______________________________________________
Assistant Superintendent for Administration
Date
□ Other: