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American Federation of Teachers
3737 Camino del Rio South, Suite 410
San Diego, CA 92108-3883
LICENSURE/CERTIFICATION FEE REIMBURSEMENT PROGRAM
Date: Campus Mailbox:
(Mesa only)
Name:
EIN:
(employee ID number)
Mailing Address:
Street City State Zip Code
Phone Number: ( ) E-mail
Area Code
College/Center Site: Adjunct: Full-time Faculty:
Department or Program:
Faculty Service Areas: 1. 2. 3.
Name of Certificate/License:
Issuing Agency or Institution:
Total Expenditure(s):
College faculty may be reimbursed for the actual cost of fees charged which directly relate to the issuance
or re-issuance of a license or certificate required by the District, after initial employment, for the unit
member to qualify for or retain his/her teaching or non-teaching assignment (not included: professional
organization dues, continuing education fees, mileage, lodging, meals, etc.). Receipts and/or other official
documentation must be submitted in order to process the reimbursement.
If the amount of requested reimbursements exceeds the amount of available resources, reimbursements
may be distributed on a pro-rata basis.
Any activities reimbursed by these funds may not also be used for salary advancement purposes or any
other type of District reimbursement.
Attached in 8 ½ x 11 inch format are:
□ Official documentation showing that employee is required to have this license to keep
his/her job with the San Diego Community College District (SDCCD) or if it is mandated
by the State of California.
□ A copy of the application filled out by employee to get the license.
□ A copy of the receipt for payment of the license (i.e., cancelled check, credit card
statement, or the equivalent).
□ A copy of the actual license received by employee.
Signature of Faculty Member: ______________________________________________
Signature
Date
Date of Expenditure(s):
