Certification and Licensure Exam Fee Reimbursement Program for M/C Employees Application Form The Program reimburses a maximum of $600 for certification and licensing exams. To be eligible for reimbursement, exams must have been taken on or after April 1, 2008. To be eligible for payment, the following documents must be submitted: 1) signed reimbursement application form for each exam costing more than $25. 2) required proof of payment. 3) proof of passing grade. It is required you send these documents by certified mail, postmarked on or before March 31, 2009. We recommend you make a copy of these documents for your records prior to mailing. The Exam Fee Reimbursement Unit is not responsible for lost, misdirected, late, or incomplete applications. Mail all documents to: Governor’s Office of Employee Relations M/C Fee Reimbursement Program 2 Empire State Plaza, 7th Floor Albany, New York 12223 The Certification and Licensure Exam Fee Reimbursement Program guidelines are available at http://www.goer.state.ny.us/mc/fee-reimb If you have additional questions, email response@goer.state.ny.us.
Employee Eligibility: You must be a New York State or Roswell Park M/C employee who meets one of the following criteria (check applicable box):
I am employed full-time or part-time, have Attendance Rules coverage, and have completed the 13 biweekly pay period qualifying period to earn and use vacation I was laid off in the past year and have not been rehired in a New York State or Roswell Park M/C position and am on the appropriate Civil Service or Roswell Park preferred list I am on full-time non-disciplinary leave (Note: If you do not meet one of these criteria, then you are not eligible. See Section B.)
1. Social Security #:
2. Name:
3. Start date with New York State:
(Required for payment by OSC) 4. Home address:
5. City:
6. State:
7. Zip:
8. Agency/Facility Code: 12. Salary Grade:
9. Agency/Facility Name:
10. Work Phone/Ext:
11. Job Title:
13. Home Email Address:
14. Reimbursement Level (Check one of the following): Full-Time Part-Time, 50% or more Part-Time, less than 50% (See Section E.) 17. Exam Provider: (See Section C.3.) _________ _________ _________
15. Exam Name:
16. Exam Date:
18. Exam Provider Address:
19. Exam Provider Phone:
20. Exam Grade:
21. Cost of Exam:
22. Job or Career-Related (Check all that apply and explain): Job-related ______ Career-related ______
23. Certification/Licensure (Check all that apply and explain): Certification _______ Licensing _______
Explain: ______________________________________ Explain: __________________________________ (See Section C.1.) Your signature will attest to the authenticity of the statements in this application, as well as the enclosed documentation. I have complied with all eligibility requirements of the Certification and Licensure Exam Fee Reimbursement Program and request reimbursement. All the information contained in this request is true and accurate. I have read and understand the guidelines to this program and agree to comply with all policies and procedures. Signature: ______________________________________________________________________ Date: ____________________________