Approval and Reimbursement Authorization Form

Approval and Reimbursement Authorization Form

Name:

Email:

Address:

Trauma Center:

Deadline for submitting form to Trauma Program Manager: 30 days from end of course

TCAR conference: Request for $100.00 in partial reimbursement for course registration fee

Attached copy of CE certificate (record of attendance)

Attached copy of receipt (e-receipt, cancelled check, credit card receipt or statement)

Approval by San Diego County Trauma Center Program Manager:

Name:

Signature:

Trauma Center

Date: