Date of Request:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Name:
*
Employee Email:
example@example.com
Clinic:
*
Start Date of Course:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date of Course:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time off required from normal schedule:
*
Yes
No
Name of Course:
*
Location of Course:
*
Cost of Course:
*
Make Check Payable to:
*
Estimated Cost of Other Expenses:
Lodging:
Travel:
Mileage:
Meals:
Progressing toward clinical certification:
*
Yes
No
Total Cost (all expenses):
*
State Licensure Period Beginning Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
State Licensure Period End Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
State of Practice - Hours Required for Period
*
List Previous Courses this Licensure Period: Name/ Date of Course, Total Expenses, Hours
Receipt Uploads - all receipts must be submitted for expenses to be reimbursed
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Continuing Education Guidelines:
Associates must complete the required six months of employment to be eligible for continuing education benefits.
Associates acknowledges that if employee terminates employment within 3 months after course completion, he or she must reimburse the full expense of the course.
Associate Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor Email for Approval:
*
example@example.com
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