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:

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