CONTINUING EDUCATION FUND APPLICATION                         SAN DIEGO IPSSA

Member Name:  _____________________________________ Date__________________ Company Name: ___________________________________________________________ Address: _________________________________________________________________ City: _________________________________ Zip: _______________________________  Course/Seminar/Program  ___________________________________________________ Course/Seminar/Program Date: ____________________________ Cost: _______________ Note: The Education Committee Chairperson (ECC) must receive Application within 30 days of course Completion. Receipt or proof of attendance must be submitted to ECC before reimbursement will be made. Give/mail to Education Committee Chair - Brian Davis 8070 La Jolla Shores Dr #421 La Jolla CA 92037