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

Subj:	REQUEST FOR MAINTENANCE OF CERTIFICATION FEE REIMBURSEMENT Ref:	(a) BUMEDINST 1500.20A
1.	Per reference (a), I request reimbursement for the maintenance of certification annual fee for (name of certification or certifying board).  I attest that I am currently board certified.

a.	Date of payment:

b.	Maintenance of certification fee amount:

2.	Requestor’s contact information:

a.	Telephone (Commercial/DSN):

b.	E-mail:

c.	Command address:

d.	Command unit identification code:

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 this request submission to Navy Medicine Professional Development Center. I will have XX years and XX months of active obligated service from the date of submission. My projected rotation date from my current command is (enter date).

4.	I understand my request for reimbursement of fees must be submitted in the same fiscal year payment to the specialty board was made.

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

Applicant’s Signature