Application for the Chapter Professional Certification Reimbursement

Valid for testing period May/June 2010

Name:
Email Address:*
Phone Number:
Company:
Title:
Approx. Date Joined HRP:
Exam Taken:	PHR SPHR GPHR
1. Please describe your involvement in HRP, the SHRM PA State Council or other SHRM related chapter/organization*. Include any active committee participation and/or positions of leadership held. *Provide name of SHRM related organization and contact information.
2. Describe how you will use the knowledge gained from the certification process to benefit HRP.
3. Describe how the certification will benefit you in your career.
Please acknowledge the following statements by electronically signing below: I am a member in good standing of the Human Resource Professionals of Central PA. I understand that the reimbursement is for up to $700.00. I am not receiving reimbursement for the exam fee or cost of the study materials from my employer or any other organization. I understand the reimbursement is contingent upon proof of my successful passing of the exam. I understand that in order to receive the reimbursement I must provide documentation confirming expenses incurred. I understand that I may be required to provide documentation from my employer confirming I did not receive reimbursement through my employer. Electronic Signature:  Date: Verification Code:* Please input the numbers you see into the box below. No spaces are necessary.