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 Chairs - John Baldwin 10226 Vista de la Cruz La Mesa CA 91941 Brian Davis 8070 La Jolla Shores Dr. #421 La Jolla, CA 92037