VCOM Institutional Policy and Procedure Manual

Appendix A Edward Via College of Osteopathic Medicine Employee Educational Aid Initial/Supplemental Application Directions: Complete Part A and sign below. Secure signatures indicating approval from your Direct Supervisor and Division Officer prior to submitting to the Director for Human Resources. Part A: To be Completed by the Employee Name: _______________________________________________________________________________________ Last First M This is an: Initial Application Supplemental Application Institution: ___________________________________________________________________________________ Degree Program (if enrolling in a full degree): _______________________________________________________ Level of Coursework: ______________________ Reimbursable Amount Per Credit Hour: _______________ Total Number of Courses Included in This Application: _______________ Describe how completion of the program will directly benefit the mission of the college and either your current position or future potential advancement at VCOM.

Reimbursement Requested for the Following Course(s): Course Number Course Name

Course End Date

*Additional courses must be listed on a separate document attached to this note, if applicable. Attach a copy of the following (check to indicate attachment):

☐ A copy of the course listing for each course for which you are seeking reimbursement or the full degree program course list if seeking reimbursement for all courses within the program and the estimated length of the single course or full degree program from the College’s website or course catalog. ☐ If requesting reimbursement for coursework or a degree program at a VCOM non-partner institution, attach two letters: ☐ A letter from you describing why they cannot complete the coursework at a VCOM partner institution. ☐ A letter from your Direct Supervisor outlining how your participation in the program will benefit VCOM and that affirms their support for your decision to pursue the program outside of VCOM’s partner institutions.

___________________________________________________________________________________________ Signature of Employee/Requestor Printed Name of Employee Date