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Participant’s Name ______________________________________________________

Department ___________________________________________________________

Name of Class _________________________________________________________

Course/Code __________________________________________________________

Date of Class __________________________________________________________

This class was taken for: (please circle appropriate one below)

TUITION REIMBURSMENT = (TR)

TUITION WAIVER = (TW)

WELLNESS REIMBURSEMENT = (W)

IMPORTANT: This portion must be completed prior to submitting this form to Human Resources:

Signature of Instructor __________________________________________________

Date: ________________________________________________________________

Signature of Participant _________________________________________________

Date: ____________________________________________

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