MAINE SCHOOL ADMINISTRATIVE DISTRICT NO. 75

50 REPUBLIC AVENUE

TOPSHAM, MAINE 04086

ADVANCE PAYMENT AGREEMENT

I, understand that M.S.A.D. No. 75 will pay for my registration in the course entitled being offered (date) Check amount requested: $

Check is to be made payable to:

Should this money be refunded to me for any reason, I shall immediately return it to M.S.A.D. No. 75.

I agree to submit a copy of transcript or proof of completion with any available grades to M.S.A.D. No. 75 within 90 days after the course completion date as set by the College or University.

I understand as well that should I not successfully complete the course, I will be obligated to pay the school district $ as arranged through payroll deduction, since course reimbursement is contractually contingent upon the successful completion of course work.

I am a _____ Full Time Employee

_____ Part Time Employee

Signature of Registrant Date

* * * PLEASE SUBMIT THIS FORM TO ACCOUNTS PAYABLE (DISTRICT OFFICE) WITH A COPY OF AN INVOICE OR BILL * * *