CONTINUING EDUCATION FUND APPLICATION SAN DIEGO IPSSA

Company Name: ___________________________________________________________

Address: _________________________________________________________________

City: _________________________________ Zip: _______________________________

Course/Seminar/Program  ____________________________________________________

C/S/P Date: ________________________Location:_______________________________

C/S/P Cost*:___________Out of Town Reimb**:__________ TOTAL Request_________

* 100% reimbursement on C/S/P cost
** $100 for SoCal (Outside SD County), $250 (Outside SoCal)

Note: The Education Committee Chairperson (ECC) must receive Application within 30 days of course
Completion. Receipt or proof of attendance must be submitted to ECC before reimbursement will be made.

Give/mail to Education Committee Chair -

Patrick Nieratko 10312 Carioca Ct., San Diego CA 92124 - 619-647-9395