Publix Reimburse Form PDF Details

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Form NamePublix Reimburse Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesreimbursable, TuitionReimbursementPublix, publix tuition reimbursement, Avg

Form Preview Example

Tuition Reimbursement Program

Undergraduate Reimbursement Request Form


After each class ends the Tuition Reimbursement department must receive a completed copy of this form, a copy of your grade report, and an itemized receipt (showing a breakdown of your tuition cost for each class and the method/s of payment) within 45 days for it to be considered for reimbursement. On-line print outs are acceptable. You may send these documents through interoffice mail, by fax to (863) 284-3325, or through the U.S. mail to the following address:

Publix Super Markets, Inc.

Human Resources/Tuition Reimbursement Program P.O. Box 407

Lakeland, FL 33802-0407

If you have any questions about the Tuition Reimbursement Program we can be reached at (863) 688-7407 ext. 54250 or at When contacting our department you will need to provide your Publix personnel number, which is located on your paycheck.

Associate Information

Name: ____________________________________________________ Publix Personnel Number: ___________________

Job Title: ________________________________________ Email Address: _______________________@_____________

Store Number or Support Department Name: ________________________________ Division: _______________________

Are you interested in pursuing a career with Publix after graduation?



If yes, in what capacity or department? ____________________________________________________________

Are you willing to relocate after graduation for a career with Publix?




What is your long term career goal?_________________________________________________________________________

School & Course Information

School Attended: ___________________________________

Declared Major: ________________________________

Current Classification:



Class(es) taken during:



Expected Graduation Month and Year: _________________

Is this your last course before graduating? Yes No





Course #

Course Title

Start Date

End Date

Credit Hrs


Payment Information - from your attached receipt(s)

Reimbursement Criteria

Total Tuition Cost




Methods of Payment

Amount of Payment



Grants and/or Scholarships*


Loans and/or Prepaid Tuition




Cash, Check, Money Order and/or Credit Card




* Tuition expenses that were paid for with grants or scholarships are not reimbursable.

For Office Use Only

To be eligible to receive reimbursement, you must

be a current and approved Tuition Reimbursement participant on the date funds are scheduled to be disbursed

pursue a qualifying major at a regionally accredited school

be an active associate with at least six months of consecutive service since your last hire date

maintain a minimum average of 10 work hours per week based on a 52 week average or entire employment if employed less than 1 year

maintain a minimum Total Performance Rating of Meets Expectations/Successful and

receive a grade of “C” or better in the class

Last Hire Date: _____/_____/______

Avg Number of Hours: __________

Did the associate’s major change?

Reimbursement is:


Did the associate change schools?

Approved in the amount of $________________________________

Met annual limit?

Denied because__________________________________________

Met lifetime limit?

Yes No

Yes No

Yes No

Yes No

Initial _________ Date _____/______/_______


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