Clinton County EMS Association
Clinton, Iowa
Continuing Education/Training/Equipment Reimbursement Form
Date:_______________
Applicant Name: ________________________
Member Name:_________________________
Payee:________________________________
Address:______________________________
Address:_______________________________
_____________________________________
______________________________________
Education/Training
(Circle one)
Initial Education
Continuing Education
Advanced Education
Course Title: ______________________________________________
Approval or Sponsor # __________________
# of Attendees _______
CEH’s Awarded: __________
Cost $______________
Requested $___________
Equipment
(Circle one)
Cash Match
Full Reimbursement
Partial Reimbursement
Equipment Description: ___________________________________________________
Equipment Cost $ ______________
Requested $_______________
Please attach attendance sheets or course completion certificate with name, certification number
and number of CEH’s awarded, packing slip or receipt if applicable and proof of payment.
I hereby state that all information given on this form to be accurate to the best of my knowledge.
____________________________________________________
Signature of Applicant
Date
CCEMSA Use Only
CCEMSA Use Only
Date Received:___________________
Approved By
Date
_______________________________
Reviewed By
Date
_______________________________
_______________________________
_______________________________
Check #________Amount $ ________