Online Professional Development Application Form
ACTEM Professional Development Reimbursement Request

Use this form to submit your PD Reimbursement request to ACTEM.

ACTEM will reimburse individuals for course and registration fees associated with the professional development activity. Course materials, lab fees, travel, hotel, meals and other similar costs will not be reimbursed. Reimbursement is limited to one approved activity per ACTEM membership year.

Full Overview: http://actem.wildapricot.org/ACTEM-PD

Email address
Name:
Your answer
School/District:
Your answer
Mailing Address:
Street, City/Town, State, and Zip Code. Reimbursement checks will be mailed to this address!
Your answer
Phone Number:
Your answer
Email Address:
Your answer
Course/PD Activity Title:
Your answer
Sponsoring Organization & Location of PD Activity:
Your answer
Start Date:
MM
/
DD
/
YYYY
End Date:
MM
/
DD
/
YYYY
Course or PD Activity Description:
Your answer
How will this course or activity increase your technology skills and knowledge?
Your answer
Registration Cost:
Your answer
District or other reimbursements:
Your answer
Remaining out of pocket registration costs:
Your answer
Amount of PD Request to be reimbursed:
(Maximum of $300 per membership year)
Your answer
Submit
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