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M Health Fairview Rehabilitation Services
Contract for Professional Association Dues Payment
*Revised 02/05To be completed by the Employee:
Employee Name:_______________________________ Job Title:_________________________
Employee Person #:___________________ Authorized Hrs:_____________________________
Home Address: City: State: Zip:
Clinic Name & Dept. Location:________________________________________________________
Clinic/Dept. Phone #:____________________ Home Phone #:________________
Name of Professional Association (for dues payment):____________________________________
Name of Specialization Certification (for payment requested):_______________________________
Professional Association Dues Payment Policy:
50% of annual professional membership incurred from state and/or national organizations may be taken out of an employee's CE allotment if:
- Authorized hours are equal to or greater than 40 hours per pay period
- Employee needs to be actively involved in the organization. *ATC employees must participate on one state, district or national committee or attend a state/district business meeting. *Reimbursement does not include special section dues or other miscellaneous fees.
*If the employee resigns or changes status to less than 40 hours per pay period within 12 months of reimbursement, he/she will be responsible for 100% of the costs.
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Signature of Employee Date ________________________________________________________________________
Signature of Supervisor Date ________________________________________________________________________
Signature of Director Date |