REQUEST FOR PAYMENT/REIMBURSEMENT OF
PROFESSIONAL FEES OR OCCUPATION TAXES
With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form.

Name:____________________________ Department:____________________________

Certification or License: ____________________________________________________

I request that The Texas A&M University System [pay on my behalf] [reimburse me] (strike one) for the following costs which are associated with maintaining the certification or license specified above. Furthermore, I certify that the licensure or certification is properly documented to be a requirement of my position. (Please attach supporting documentation for payment/reimbursement requested.)

COSTS FOR WHICH PAYMENT/REIMBURSEMENT IS REQUESTED: $________

CERTIFICATION OR LICENSURE PERIOD: (from) ___________ (to) ____________

Under State law, payment/reimbursement by The Texas A&M University System (System) of these costs is specifically conditioned upon the System receiving an adequate return on such expenditure. I understand that the System's agreement to make payment/reimburse me for such costs is expressly made contingent upon my continued employment with the System Administrative and General Offices for the duration of the certification or licensure period specified above.

In consideration of such payment/reimbursement as may be made by the System hereunder, I contract and agree that should I cease employment with the System Administrative and General Offices for any reason whatsoever during such certification or licensure period, either voluntarily or through termination of employment, I shall be liable to repay the System for a pro rata portion of the amount of professional fees or occupation taxes paid/reimbursed by the System which corresponds to the amount of time remaining in the certification or licensure period.

____________________________________ (Signed)

____________________________________ (Date)

Approved:

__________________________________ Department Head

A copy of the approved form should be sent to the System Human Resources Office, MS 1117. The original approved form is to be attached to the voucher requesting payment.