CARRIE M. HALL FUND

of the

Alumni Association Peter Bent Brigham School of Nursing, Inc

 

Application for Tuition Reimbursement

 

Name_________________________________Date:___________________________

Address:______________________________________________________________

City:__________________________________State:_____Zip___________________

 

Yr of PBB Grad:_________States & Registration No:__________________________

Course Title:___________________________________________________________

Date Course Completed:___________________________Cost:__________________
Course Title:___________________________________________________________

Date Course Completed:___________________________Cost:__________________

Course Title:___________________________________________________________

Date Course Completed:___________________________Cost:__________________

College/University:_____________________________________________________

Amount Requested:______________Signature:________________________________

 

Note:*             To be eligible for tuition reimbursement, you must be an

                        Ongoing dues paying member of the PBB SON Alumni Association.

Delinquent dues must be paid before reimbursement is awarded. You may refer any questions about your dues status to Joan Seiberth, Assistant Treasurer.

                        *Reimbursement money is awarded depending on the availability of funds

                        *A maximum of $3000.00 (three thousand) per member may be requested.    

                          Awards will be granted upon proof of passing grade for the course(s) and

                          evidence of full dues payment.

                        *Application should be submitted within one year of completion of

                          the course.

 

Please Submit the Following:

 

Send to:            Joan Seiberth, AssŐt Treasurer

                        44 Maidstone Drive

                        Merrimack NH 03054

                        jbseiberth@yahoo.com

 

 

Do Not Write Below This Line

Action By Officers and Board of Directors

 

Approved:_________________________Amount:_______________________________

Disapproved:_______________________Reason:_______________________________

Date:________________Signature:___________________________________________