LEARN TO EARN STIPEND REQUEST FORM

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					                                                                                    LEARN TO EARN
                                                                                STIPEND REQUEST FORM



                                                                                   Applicant Information
Name:                                                                                                 Membership #:
Date of Birth:                                                                   SSN:                                 Phone:
Current Mailing Address:                                                                              New Address: Yes or No (If yes submit new W-9)
City:                                                                            State:                               ZIP Code:
School:                                                                          Director:                                                       Hire Date:

                                                                                  Training Information
                                                    (Please fill out another form completely if you have more than 5 trainings)


                       Title of Training                                          Date of             Number                      Agency Offering Training
                                                                                  Training               of
                                                                                                       Hours




            Directions for submission:
                1. Requests will only be collected May 15th- June 15th and November 15th- December 15th. Late or
                    incomplete submissions will not be accepted.
                2. Attach a copy of your In-Service Training Record or Certificate of Completion to verify each
                    training.
                3. If you have questions please contact Selena McNeely, at 321.637.1800 ext 2055.
                4. Remit to: PO Box 560692 Rockledge, FL 32956
                5. Please allow 8-10 weeks for processing.

            I herby certify that the trainings listed above qualify as additional training hours as defined in the program guidelines. I also certify
            that I have attended each of these trainings in its entirety.

            _________________________________________________________________                                                     ___________________________________________________
            Applicant Signature                                                                                                    Date

            I herby certify that the above-named applicant has been continuously employed at my facility a minimum of 6 months.

            ________________________________________________________________                                                       __________________________________________________
            Director/ Owner Signature                                                                                              Date
                                                                                  For Coalition Use Only
_____________________________________________________________________________
Authorized by Sky Beard, Executive Director                             Date    Employment Level _______________                  Received in AP________________Date____________niitials

Number of Trainings Submitted_______________________                            Training Hours Approved______                     Coding____________________________________________________

Documentation Attached________________________________                          Stipend Total______________________               Entered_______________________Date____________Initials

Application Received______________________________________                      Copies given to Finance_________                  Posted________________________Date____________Initials

                                                           Check mailed to Participant__________________ Date_________________ Check #