Atlanta Police Department

Atlanta Police Foundation

Tuition Reimbursement Program

2007/2008 Calendar Year

Application Package

Applicant Name:
Applicant Position & Assignment:
Applicant Contact Number:
Applicant E Mail Address:

For consideration for tuition reimbursement please return this completed application package within 30 days of receiving grades and also within the published timelines. Return completed package to the Police Academy in person for consideration by the Scholarship Committee. You must have your package logged in and get the receipt in person. All sections must be filled out completely or your application may not be considered.

Received at Academy: _____________ Received by: __________________

First Review: __________________________________________________

Second Review: ________________________________________________

Third Review:__________________________________________________

Recommended Amount: ______________________________________

(For Committee Use Only)

YOU MUST COMPLETE ALL AREAS IN ORDER FOR THE COMMITTEE TO CONSIDER YOUR APPLICATION FOR REIMBURSMENT

Applicant’s Name:
Date of hire:
Name of and location of the University/College you attended:
Where is your University/College Accredited?
The Council for Higher Education Accreditation (CHEA) http://www.chea.org/Directories/regional.asp lists the accepted institutions.

What is your program of study? (Ex: BA Criminal Justice, MS Public Administration, etc.)
For which semester/term are you requesting reimbursement?
What is your cumulative (all classes) grade point average (GPA) for the semester you are
requesting reimbursement for? (Attach grade sheet) GPA
What total Tuition costs incurred are you requesting reimbursement for?
$	(Receipts must be attached). This is a reimbursement program.
You must show that you have paid your tuition and that you received no grants or scholarships for the classes you are requesting reimbursement for.
Have you received any Grants or Scholarships to cover any expenses for this semester?
If so when and how much?
Are you or have you requested tuition reimbursement in any form from another source
other than the Atlanta Police Foundation?
If so when and how much?

Certifications/Acknowledgments

I certify that I am an employee of the Atlanta Police Department and that information entered on this form is true and accurate. I certify that I am not receiving reimbursement funds from another source for the semester/term requested in this application. I am requesting reimbursement for my personal funds expended for college tuition from the Atlanta Police Foundation. I acknowledge that it is my responsibility to submit complete, accurate, and timely documentation as requested by the committee.

Applicant Signature

Applicant Acknowledgement

I do hereby acknowledge and agree to maintain employment with the City of Atlanta for a period of not less than 36 months following the reimbursement of any tuition, books or fees by the Atlanta Police Foundation. If I resign, retire or involuntarily separate from the employment of the Atlanta Police Department within 36 months of reimbursement, I must reimburse the Atlanta Police Foundation the full amount of the reimbursement. I do hereby authorize the City of Atlanta to deduct from my salary on behalf of the Atlanta Police Foundation, any reimbursements paid if the service requirements are not met.

Applicant’s Signature
Date

Immediate Supervisors Certification

I certify that the applicant/employee has maintained satisfactory performance. I have reviewed this application for completeness.

Supervisor Comments:
Immediate Supervisor’s Signature
Date

ATLANTA POLICE DEPARTMENT

Request for Atlanta Police Foundation Funds

Request by:	Name
APD ID #
Division	Section	Unit

I would like to request funding from the Atlanta Police Foundation for
The purpose of this request is as follows:

Make Check Payable to:

Note: Attach any documentation that describes the need for funding along with invoices.

For APF Use Only

Amount requested:
Amount approved:
/	/
Requestor Signature	Title	Date
/
/
Supervisor Signature
Title	Date

APF Liaison

Program that will fund the request (if applicable)

Recruitment
Mounted Patrol
Affordable Housing
Training
Scholarship
Crime Stoppers

APF Liaison Signature
Date

Program Committee Chair:
Approved
Not Approved

Program Committee Chair Signature
Date

Deputy Chief of SSD:
Approved
Not approved
D/C SSD Signature
Date

Assistant Chief of Police:

Approved

Not approved
A/C Signature
Date

Chief of Police:

Approved

Not approved
COP Signature
Date

APF President/CEO:

Approved

Not approved
APF President/CEO Signature
Date
APF Resource

Investment Committee:

Approved

Not approved
APF RIC Chair Signature
Date

Form APD 261 Revised 6/9/08

4

ATLANTA POLICE DEPARTMENT

vlivsey

2008-06-09

City of Atlanta