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N.C. Department of Health and Human Services <br />Page <br />of <br />FY 2011-2012 <br />CONSOLIDATED AGREEMENT <br />Public Health Nursing Training Funds <br />Reimbursement Request <br />Public Health Nursing & <br />Professional Development <br />Office, Section, or Branch <br />Contractor (County Name) <br />Name(s) of Participant(s) <br />*Amount Requested: $ <br />Health Director Signature <br />Contact Person Signature <br />( ) - <br />Telephone Number <br />'This form is to be used when requesting reimbursement. Submit this reimbursement request directly to: <br />Public Health Nursing & Professional Development <br />DHHS -Division of Public Health <br />1916 Mail Service Center <br />Raleigh, NC 27699-1916 <br />Reviewed by: <br />N/A <br />Contract Number <br />Public Health Nurse Training <br />Activity <br />Course attended Date Attended (Mo. & Yr.) <br />Date <br />DHHS 3300 (Revised Ol/11) <br />PHNPD {Review 12110) Initials Date <br />