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F4.3 - Educational Assistance Fund Form for Part III and Nurse Managers/Supervisors

Courses & programs

Name of course or program

Identify degree

Masters

Bachelors

Other

Institution

Start Date

Completion Date

Tuition

Books

Total Amount

Add another course or program Remove

Workshops & conferences

Name of workshop or conference

Institution

Start Date

Completion Date

Registration

Materials

Total Amount

Add another conference or workshop Remove

Total Amount:

Supporting documentation

Explain your reason(s) for taking course(s)/program(s) listed above.

Attach course information or program outlines, if available

Maximum file size: 5MB

Attach all relevant receipts

Maximum file size: 5MB

Accept conditions

If I receive financial assistance, I agree to provide proof of completion of the course or seminar. I understand that any courses offered or required by my employer will NOT be funded and that incomplete applications will be rejected.

Digital Signature

Date

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