Research Corporation of the University of Hawaiʻi

RCUH Tuition Reimbursement Program Application/Authorization Form
Attachment 1
Employee Name:___________________________________________ Employee Number:___________________________________ Phone Number:_______________________ E-mail Address:___________________________________________________________ Job Title:_____________________________________ Project:___________________________________________________ Principal Investigator(s):________________________________________________________________________________________ University of Hawaii Campus:  Manoa  Maui  Hilo  Other
If other, College/University Name:________________________________________________________________________________ (If attending a course of instruction not offered through the University of Hawaii system, please attach the current tuition and fee schedule for your school, a current course description, and justification that it is a course not similarly offered at a UH campus.)
Course Number/Name:_________________________________________________________________________________________ Course Level:  Undergraduate  Graduate  Post-Graduate
Course Description: (Please describe the course and its relevance to your position at RCUH. Attach additional page if necessary.) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
Course Semester:  Fall  Spring  Summer
Course Start Date:________________________________ Estimated Completion Date:__________________________________
Applicant Certification of Awareness (Please initial next to each item as acknowledgement):
_____ I verify that I am not receiving any other type of educational assistance through the GI Bill, scholarships, or other tuition reimbursements. I am not on a disciplinary or leave status.
_____ I am aware that RCUH will only reimburse the cost of three (3) credits per academic semester or nine (9) credits per calendar year and the rate will be limited to the cost per credit for Hawaii residents at UH Manoa.
_____ I verify that this course is directly applicable to my job duties, qualifications or is a part of a defined career-path which is part of a planned reclassification of my current job.
_____ I am aware that I will receive the tuition reimbursement upon the successful completion of the course with a grade of “C” or better and will submit my final grade report to the Director of Human Services within thirty (30) days of course completion.
_____ I am aware that this program may be modified or terminated at the discretion of the RCUH Board of Directors.
I have read the RCUH policy pertaining to the Tuition Reimbursement Program (3.460) and agree to abide by the requirements as stated. I understand that I am responsible for my own tuition bills regardless of the amount of assistance provided by the RCUH.
__________________________________________ __________________________ Applicant Signature Date
3.460 RCUH Tuition Expense Reimbursement Policy
Instructions: Complete this form and receive your Principal Investigator’s review/endorsement PRIOR to the start of the semester.
You must attach a copy of your Course Registration form to this application form. This form must be turned in to the RCUH Human
Resources Department NO LATER THAN the close of business on the FIRST DAY of classes in the applicable semester. Please print
or type the information below.
Effective July 1, 1997 (rev. 11/2016)
Name: Course Start Date:
Principal Investigator’s Review and Endorsement
Attachment 1
INTERNAL PROCESSING (RCUH HR STAFF USE ONLY)
3.460 RCUH Tuition Expense Reimbursement Policy
I have discussed the contents of this application with my employee and I agree that the course is job related to his/her position description. I am providing additional justification if this course is not directly related to my employee’s position description (i.e. stated in the minimum qualifications), however I believe the course has relevance to this employee’s job.
__________________________________________ __________________________ Principal Investigator Signature Date
__________________________________________ Print Name
STATUS OF APPLICATION
_____ Application is approved for the reimbursement amount of _________________.
_____ Application is denied due to _____________________________________________________________________________
FTE (%):________ Regular (Y/N):________ Hire Date:________ Other F.A. (Y/N):________ Verified By:_______
Previously Received Reimbursement (Y/N):________ If yes, how many credit hours this calendar year?________
__________________________________________ Director of Human Resources &
Chair, RCUH Tuition Reimbursement Program Committee
INTERNAL PROCESSING (RCUH HR STAFF USE ONLY)
_____ Record of Course Completion (Grade of “C” or Better)
__________________________________________ Authorization to Process Reimbursement
__________________________ Date
Date Received:______________________________________
__________________________ Date
PLEASE SUBMIT COMPLETED APPLICATION TO [email protected]
Effective July 1, 1997 (rev. 11/2016)