[Table of Contents] [ Section 1 ] [ Section 2 ] [ Section 3 ] [ Section 4 ] [ Section 5 ] [ Section 6 ] [ Section 7 ] [ Section 8 ] [ Section 9 ] [ Section 10 ] [ Section 11 ] [ Section 12 ] [ Section 13 ] [ Section 14 ] [ Appendix A ] [ Appendix B ] [ Appendix C ] [ Appendix D ] [ Appendix E ] [ Appendix F ] [ Appendix G ] [ Appendix H ]

 Appendix E

Please Download this Form in one of the following formats:

MS WORD     OR     ADOBE ACROBAT

Department of Health and Human Services’ Office of Adult Mental Health Services

and The Center for Learning
 

This form may be copied.

 MHRT/COMMUNITY TUITION REIMBURSEMENT REQUEST

 Application must be mailed at least 30 days before the start of the class. Funds are very limited. Applicants are
cautioned to not make coursework plans based on an assumption of reimbursement.

A.  -  IDENTIFICATION: (NOTE: All information MUST be filled in for this section in order for your request to be processed.)

PLEASE PRINT CLEARLY! Illegible or incomplete requests will be returned unprocessed. 

Name: ______________________________Work Tel: _____________ SS.#:                                    

Your Home Address:________________________ City:_______________________ Zip:             

Agency (Full Name):                                                                                                                                                             

Agency Address:___________________________ City: _______________________ Zip:            

Address reimbursement check is being mailed to:  (Circle One)            HOME                          AGENCY

B.  -  ELIGIBILITY:   (A response is needed to each question in this section.  A “yes” answer is required for each question.
“No” answers and/or false statements will result in denial of tuition reimbursement) 

C.  -  COURSE IDENTIFICATION:              (Please enter cost of tuition for the class:  $__________ )

School, Campus & Location:                                                                                                        
                                               (Note: Please list the name of the institution you will be attending in the above information)

Course Title:                                                                                                                             
                                                (Note: A separate request sheet must be made out for each course.)

                Reimbursement to: (Circle One)      SELF       AGENCY      Undergraduate    Graduate
                                                        Course ____         Course ____

D.  -  SEMESTER:   Please list the Semester/Year of the course here:                                                                                   

E.  -  APPROVAL:   Supervisor’s Name: _____________________________  Date:                            
                                            (Please Print Clearly)

                                                                                                                                                                                    (Supervisor Signature)*                                          (Applicant Signature) 

*NOTE:  Supervisor’s signature indicates that all Eligibility Statements are accurate and that individual is authorized
to submit this request. 

BOTH STUDENT & SUPERVISOR SIGNATURES ARE REQUIRED

Completed form must be returned to: The Center For Learning, 45 Commerce Dr. Suite 11, Augusta, ME  04330 Attn:  Tuition Reimbursement or faxed to 626-5022.  The DHHS Office of Adult Mental Health Services will reimburse only the actual tuition costs for the course (up to a maximum tuition rate for an undergraduate 3 credit course at USM).  Students understand they are responsible for books and fees.  Reimbursement will be made after receipt of an official transcript for the course with a grade of "C" or better.  Students must submit the transcript directly to the Center For Learning for reimbursement.  Grades must be mailed within 30 days of close of class. There is a limit of three classes per fiscal year (July 1 through June 30).

[Table of Contents] [ Section 1 ] [ Section 2 ] [ Section 3 ] [ Section 4 ] [ Section 5 ] [ Section 6 ] [ Section 7 ] [ Section 8 ] [ Section 9 ] [ Section 10 ] [ Section 11 ] [ Section 12 ] [ Section 13 ] [ Section 14 ] [ Appendix A ] [ Appendix B ] [ Appendix C ] [ Appendix D ] [ Appendix E ] [ Appendix F ] [ Appendix G ] [ Appendix H ]