Educational Reimbursement Form

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

EDUCATIONAL REIMBURSEMENT FORM

IN ORDER TO BE REIMBURSED: you must submit this form within sixty (60) work days after the availability of semester grades and upload the following below:

1. ENROLLMENT AND PAYMENT PRINTOUT

2. COPY OF GRADE REPORT

3. BOOK RECEIPTS (for required books)

This form is to be used to request reimbursement for the successful completion of courses taken at El Camino College by regular permanent employees, their spouses, and/or their legal dependent children. Fees are reimbursed for successfully completed courses upon completion of semester. Only employees are eligible for book reimbursement (for required books purchased with 10% employee discount at the El Camino College Bookstore).

Employee's Name*

First Name

Last Name

Department*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Datatel ID*

Colleague ID

Phone Ext. *

Email*

Confirm Email *

Classification*

Student's Name*

First Name

Last Name

Relation to Employee*

Semester Enrolled*

EMPLOYEE ELIGIBILITY CHECK LIST

Are you a non-probationary employee?*

Yes No

STOP - Please do not proceed. You have to be a permanent (non-probationary) employee in order to qualify for a educational reimbursement.

Are you applying for yourself, your spouse, or a legal dependent?*

Yes No

STOP - Please do not proceed. You can only apply for yourself, spouse, or legal dependent.

Are you on approved medical or disability leave?*

Yes No

If you are on approved medical or disability leave, you must submit formal written request through the Exceptions Committee.

REIMBURSEMENT REQUESTED

Enrollment Fee* $

Health Fee $

Student Representation Fee $

Books - Only employees can be reimbursed for books $

Books must be purchased with 10% employee discount at the El Camino College Bookstore

Total Requested $

DOCUMENTATION REQUIRED

Upload Enrollment and Payment printout*

No File Chosen

File uploads may not work on some mobile devices.

Registration Statement - can be obtained from the cashier's window (next to the bookstore)

Upload a copy of the Grade Report*

No File Chosen

File uploads may not work on some mobile devices.

Grade Report must include the semester, year, and grade issued for the class.

Upload Book Receipt

No File Chosen

File uploads may not work on some mobile devices.

Only book receipts from the El Camino College Bookstore are acceptable for reimbursement.

HR TECHNICIAN REVIEW

Is the application approved/complete to go to the HR Director?*

Yes No

Classified Account Number:

11-55250-00-67300-8500

ECCPOA Account Number:

11-55251-00-67300-8500

Confidential Account Number:

11-55252-00-67300-8500

Faculty Account Number:

11-55254-00-67300-8500

Account Code: *

Classified Account Number: 11-55250-00-67300-8500 Confidential Account Number: 11-55252-00-67300-8500 ECCPOA Account Number: 11-55251-00-67300-8500 Faculty Account Number: 11-55254-00-67300-8500

The form is incomplete or not approved to go to the HR Director for the following reason(s):

Application reviewed by:*

HR MANAGEMENT REVIEW

HR Director's Name*

First Name

Last Name

HR Director's Decision*

Approved Denied

HR Director's explanation for denying this request

ACCOUNTING REVIEW

Is the total refund amount the same as above?*

Yes No

If the amount is not the same, what is the amount?

Notes (Optional):