LEARN TO EARN
STIPEND REQUEST FORM
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:
(Please fill out another form completely if you have more than 5 trainings)
Title of Training Date of Number Agency Offering Training
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
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 #