Date of Request

From:  Name of Applicant, Corps, USN, Command Address
To:	Commanding Officer, Navy Medicine Professional Development Center (Appropriate Code), 8955 Wood Road, Bethesda, MD 20889-5628
Via:	Commanding Officer, Applicant’s Command
Subj:	REQUEST FOR CERTIFICATION EXAMINATION FUNDING Ref:	(a) BUMEDINST 1500.20A
(b) Financial Management Policy Manual 03138

1.	Per reference (a), I request funding to participate in the certification examination for (name of certification examination, written or oral board, part 1 or 2) as described below:

a.	Inclusive dates of examination: (Including leave in conjunction with temporary additional duty (TAD) and travel dates).

(1)	Date travel starts:

(2)	Date of examination:

(3)	Date travel ends:

b.	Location of nearest testing site to permanent duty station:  (Including overseas)

c.	Mode of transportation desired:

(1)	Originating point:  (specify airport)

(2)	Destination point:  (specify airport)

d.	Sponsor or agency offering the examination:

e.	Examination fee:

f.	Government quarters are or are not available.

g.	Government messing is or is not available.

  Subj:	REQUEST FOR CERTIFICATION EXAMINATION FUNDING

2.	Requestor’s contact information:

a.	Commercial telephone:

b.	DSN telephone:

c.	E-mail:

d.	TAD office point of contact (POC):

e.	TAD office POC commercial telephone:

f.	TAD office POC e-mail:

3.	I am not in receipt of release from active duty or retirement orders. I agree to remain on active duty for at least 1 year from the date of the certification examination. My projected rotation date from my current command is (enter date).

4.	If this request is not approved, I understand any advance payment of fees or related expenses from personal funds will be my responsibility.

5.	I understand that I must comply with reference (b) by submitting a travel claim to my local TAD office, Personnel Support Detachment, or Defense Travel System within 5 calendar days of return from travel.

6.	I will forward a copy of the official results to my local command credentialing office and to the Navy Medicine Corps Planner (BUMED-M13), within 5 business days of receipt.

Signature of Member