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PROFESSIONAL DEVELOPMENT REIMBURSEMENT FORM
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(Non-travel related request)
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Date:
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Full Name of Employee:
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Employee ID number:
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Phone number:
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Email:
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Supervisor's Name:
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Detail of expenses incurred:
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DATE
(MM/DD/YY)		CategoryDescriptionCost
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 Training (MCLE or other)
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Professional Association Dues
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 Books/Reference guides
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 Software
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 Certification Fees
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 Laptop/Tablet
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 Office Equipment/Technical Devices
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 Supplies
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 Other (Describe)
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 Other (Describe)
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TOTAL $ -
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Additional Info or comments:
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EMPLOYEE SIGNATURE
DATE
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By signing, employee verifies that all requests included for reimbursement are eligible per the current MOU.
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MOU 29 and 31 members only:
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The employee verifies that the upfront payment provided per MOU 29/31 has been fully expended and that the expenses requested above were not paid from the up-front payment.
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Initials Required
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Requirement: Attach copies of invoices and, if applicable, MCLE provider-issued certificate of participation. Submit to the Business Office within 30 days of completing course to ensure timely reimbursement.
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