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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:_________________________________________
Date of Expenditure(s): ___________________________________________________
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 will 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
