Tuition Reimbursement Request Form

2021-2022 Teachers

If you are filing for tuition reimbursement, remember that this request pertains to graduate course work for the period covering July 1, 2021 through June 30, 2022. All reimbursement requests must be RECEIVED by May 3, 2021.

Requestor Name:*

Work Location:*

Andover High School Bancroft Elementary School Doherty Middle School High Plain Elementary School Sanborn Elementary School Shawsheen Preschool South Elementary School West Elementary School West Middle School Wood Hill Middle School TOPS

Email:*

Graduate Program:*

Type of Program:*

Graduate Doctoral Other

College:*

Enrollment Date:*

Has the graduate program been approved by the Assistant Superintendent?

Yes

No

Course Title and Number:*

Semester:*

Summer 2020 Fall 2020 Winter 2021 Spring 2021

Per Credit Cost: *

Number of Credits: *

Total Amount to be Reimbursed: (entered amount can not exceed $1500)*

Only will be reimbursed for one course up to 3 credits.

Comments: