Psychological Testing Reimbursement Form

South Carolina Criminal Justice Academy

Psychological Testing Reimbursement Form
Date

Month Day Year
Date
Applicant Name *

First Name Middle Name Last Name Suffix
Last 4 of applicants Social Security Number: *
Will the applicant be hired as a Class 1 Officer by your agency? *

Yes No
If hired, Date of hire

Month Day Year
Date
Agency Name *
Point of Contact Name *

First Name Last Name
Point of Contact Email
example@example.com
Phone Number

Area Code Phone Number
Reimbursement should be mailed to: *
Agency Name

Address *

Reimbursement Amount: (Reimbursements are made for the actual cost up to $350.00) *
Upload copy of bill. This should show the Applicants Name, Doctors Name as well as the cost. *
By entering your name below, you certify that you are authorized to submit this form and the above information is true and correct: *
Authorized Signature Academy ID #
xxxx-xxxx
Should be Empty: