All information is required.

First Name of Employee:
Last Name of Employee:
Company:
Email Address:
Phone Number:	()
Work Address
Street:
City/State/Zip:	, AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISDSCTNTXUTVTVAWAWIWVWY

Application Information
Length of time with Employer:
Job Title/Department:
Full Title of Course:	(e.g. Intro to Business)
Course completed at:	(e.g. CSU Los Angeles)
Starting Date:	JanFebMarAprMayJunJulAugSepOctNovDec  01020304050607080910111213141516171819202122232425262728293031  10
Ending Date:	JanFebMarAprMayJunJulAugSepOctNovDec  01020304050607080910111213141516171819202122232425262728293031  10
Degree Program (please list your field of study):
How does this course assist you with your job?
Tuition fee:	$ (Excludes misc. fees, e.g. student, health, parking)
Books:	$ (Applies only to Retail Management Certificate Courses)
Check if this course is part of the Retail Management Certificate Program. (For more information, visit www.wafc.com)

1. The Foundation will reimburse employees up to $100 per course. Employees are limited to a maximum annual reimbursement of $600.
2. The Employee must have completed this course with a grade of C or above (or a certificate of completion for seminar courses). To request reimbursement, submit this form, completed in full, along with a receipt and proof of satisfactory completion from the school where the course was taken (an official transcript is not required).
3. Reimbursement applications must be received by CGAEF within TWO MONTHS from the end of the course (no exceptions are allowed).
4. Employer must be a current member of the California Grocers Association. Employee must work a minimum of 20 hours per week to qualify for this program and must be employeed with the qualifying company for 6 months.
5. Both Employer and Employee acknowledge that this Career Development Program is on a "first come, first serve" basis; reimbursements will be approved/disapproved in the order in which they are received. Courses will be approved based on the following priority: 1) Retail Management Certificate Courses; 2) time in the industry and 3) applicability to the food industry (see list on www.cagrocers.com). Approval is granted without regard to race, color, creed, religion, age, gender, disability, national origin, sexual orientation or other protected status. It is possible that funds for this program may be depleted by the time this application is processed. The CGAEF Board of Trustees has the sole discretion to disapprove any application and reserves the right to limit the amount of funding to any one company or individual based on aggregate usage or available funds.

After submitting this application, you will be given a signature page to be printed that must be signed by both yourself and your supervisor. Please return the completed signature page along with the required paperwork outlined above.

By submitting this application, you acknowledge that you have taken this course voluntarily and paid for it with personal funds.

If you have questions, please contact Brianne Korte by calling (916) 448-3545 or by email to bkorte@cagrocers.com.