Alumni Association
Peter Bent Brigham School of Nursing, Inc
Name_________________________________Date:___________________________
Address:______________________________________________________________
City:__________________________________State:_____Zip___________________
Yr
of PBB Grad:_________States & Registration No:__________________________
Course
Title:___________________________________________________________
Date
Course Completed:___________________________Cost:__________________
Course Title:___________________________________________________________
Date
Course Completed:___________________________Cost:__________________
Course
Title:___________________________________________________________
Date
Course Completed:___________________________Cost:__________________
College/University:_____________________________________________________
Amount
Requested:______________Signature:________________________________
Note:* To
be eligible for tuition reimbursement, you must be an
Ongoing
dues paying member of the PBB SON Alumni Association.
Delinquent dues must be paid before reimbursement is
awarded. You may refer any questions about your dues status to Joan Seiberth,
Assistant Treasurer.
*Reimbursement
money is awarded depending on the availability of funds
*A
maximum of $3000.00 (three thousand) per member may be requested.
Awards will be granted upon proof of
passing grade for the course(s) and
evidence of full dues payment.
*Application
should be submitted within one year of completion of
the course.
Please
Submit the Following:
Send
to: Joan
Seiberth, AssŐt Treasurer
44
Maidstone Drive
Merrimack
NH 03054
Approved:_________________________Amount:_______________________________
Disapproved:_______________________Reason:_______________________________
Date:________________Signature:___________________________________________