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BK:00026 PG - 0484 <br />N.C. Department of Health and Human Services <br />Page <br />CONSOLIDATED AGREEMENT <br />Centralized Intern Training Funds <br />Reimbursement Request <br />Environmental Health Section <br />Centralized Intern Training and <br />Authorizations <br />Office, Section, or Branch <br />Contractor (County Name) <br />Name(s) of Participant(s) <br />Course attended <br />*Amount Requested: S <br />Health Director Signature <br />Contact Person Signature <br />Date <br />Telephone Number <br />N/A <br />Contract Number <br />Centralized Intern Training <br />Activity <br />Date Attended (Mo. & Yr.) <br />This form is to be used when requesting reimbursement. Submit this reimbursement request directly to: <br />Environmental Health Section, <br />Centralized Intern Training & Authorizations <br />DHHS - Division of Public Health <br />1632 Mail Service Center <br />Raleigh, NC 27699 -1632 <br />Reviewed by: <br />of <br />FY 2014-2015 <br />DHHS 4125 (New 10/13) <br />AFNC (Review 10/16) initials Date <br />