Name of Applicant: _____________________________________________ Date: ______________

Years of Service: ___________ (You must have completed three years of service to FRA.
These years need not be consecutive.)

Date of Last Reimbursement/Loan: ___________________ (Indicate academic year/semester.)

Dates you will attend school: ________________________ (Classes completed prior to June 30th will
be reimbursed in that fiscal year.)

Description of Course of Study: Indicate the courses you plan to take. These must be directly
related to your role at Franklin Road Academy.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

College or University: ____________________________________________________________________
(If these courses are available and less expensive at another local institution, consider taking those courses.)

Maximum annual reimbursement is the amount equivalent to two semester courses at the rate per graduate hour at a Tennessee State University. Note that you must earn a B or above in each course to receive reimbursement.

Tuition per Quarter/Semester Hour: $__________

Total Tuition Cost (Tuition /On-line Fee/ Lab Fees Only): $ __________ (This program does not cover cost of
books, supplies, registration or parking.)

Employees who remain at Franklin Road Academy for three years after receiving a reimbursement/loan will have that loan completely forgiven. If the employee should depart before the three years have passed, the employee is then responsible for the prorated “unearned” amount. (i.e. If employee leaves one year after reimbursement, they are responsible to repay 2/3 of loan. If employee leaves two years after reimbursement, they must repay 1/3 of loan).

AGREEMENT:
Should my pay be terminated or interrupted before three years, I agree to pay the reimbursement/loan amount in lump sum or as agreed to by the Chief Business Officer.

________________________________________
(Employee Signature)

Submit to the Division Dean and the Academic Dean
no later than April 1 for the Summer or Fall semester
and November 1 for the Winter semester.

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Approved ________ Disapproved ________ Date: ________________

Signature of Approving Official: __________________________________________________________