The completion of this form does not guarantee funding or further authorize an employee to paid absences in support of educational programs. The form should be sent to Human Resources. A request is only authorized when approved by the director of human resources.
SECTION 1 – Employee Information
Request Date:	Semester Requested:
(i.e., Fall 2020, Spring 2021)
Employee Name:	Employee ID Number:
Work Unit/Region:	Department/Work Area:
Email:	Work Phone:
SECTION 2 – Course Information
Higher Learning Institution or University Name:
Degree Plan:	Degree Completion Date:
Course Description	Dates	Credits	Cost Per Hour	Total Cost
(e.g., ENG 101 – English Comp)	Aug. 21-Dec. 10, 2020	3	$225.00	$675.00
Do you plan to request reimbursement for books up to the allotted amount?	Yes	No
SECTION 3 – Program Participation Election (can only choose one)
Educational Tuition Assistance Program (ETAP)
I understand that I am responsible for all costs associated with enrollment and shall not be dependent on ETAP for course or degree completion.
(Initials)
Educational Paid Leave Program (EPLP)
I understand that I am responsible for class attendance or course participation requirements and shall not be dependent on EPLP for course or degree completion.
(Initials)
SECTION 4 – Employee Signature of Understanding
I attest that I have read VDOF Policy and Procedure 8-5, attached a degree completion plan, understand the guidelines for participation in ETAP or EPLP.
VDOF Employee Name	VDOF Employee Signature	Date
SECTION 5 – Supervisor Acknowledgement
In the most recent performance year, did the employee obtain at least a contributor evaluation?	Yes	No
Is this employee pending a disciplinary action?	Yes	No
Does the employee have an active written notice?	Yes	No
Do you support participation in education programs for development and growth for this employee?	Yes	No
VDOF Supervisor Name	VDOF Supervisor Signature	Date
SECTION 6 – VDOF Human Resources Approval
Date Received:	Approved	Not Approved
VDOF Director of Human Resources Name	VDOF Director of Human Resources Signature	Date