RN SPECIALITY CERTIFICATION OR RECERTIFICATION REIMBURSEMENT FORM

SEIU 1199NW Healthcare Training Fund


Standard processing time once all standard backup documentation received - 30 Days

Under penalty of perjury, I state that the information provided is correct. By signing this form, I approve the Training Fund to issue funding on my behalf.
EMPLOYEE INFORMATION (your name should match what your employer has, no nicknames please)



















Professional Development Information










Required Back-Up Documentation:


Certification or Recertification by exam:

All applicants must show proof of payment & cost and proof of completion for reimbursement.

Proof of Payment & Cost:
Plase submit a valid Invoice Receipt from the organization you applied for your certification through. The Invoice will show the Organizations name, Your name, the Date of Payment, The total amount paid (including fees) and a detailed desription of what you paid for.

Proof of Completion:
Your benefit pays for your exam costs regardless of Pass/Fail outcomes. You must submit a document showing that you completed the exam. This must show the name of the sponsering organiztion, as well as your name, and the name of the certification.

Recertification by any means other than exam:
Must submit documents showing proof of payment and evidence of recertification in your name. Your proof of payment must include your name, the name of the sponsoring organization that was paid, the amount paid, and the date paid.

SEIU 1199NW Training Fund | 15 S. Grady Way, Suite 321 | Renton, WA 98057 | (425) 255-0315 | www.healthcareerfund.org | members@healthcareerfund.org