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Consolidated Agreement FYI <br />ATTACHMENT E <br />Centralized Intern Training <br />Funds Reimbursement Request <br />Page 23 of 33 <br />Page of <br />FY 2017-2018 <br />Invoice # <br />Name of REHS- <br />Intern (or REHS) <br />County Health Department <br />& Address <br />CIT Modules & <br />Dates Attended <br />Subsistence <br />Reimbursement <br />Mileage <br />Reimbursement <br />Total Amount per <br />RENS Intern <br />GM -General Module <br />(Food/I.odging) <br />(1 round trip per <br />FPF-Food Module <br />2 attendees) <br />OSW -Onsite Water <br />Protection <br />532732 <br />532731 <br />*Total Amount Requested 1 $ <br />Health Director Signature <br />Contact Person Signature <br />Date <br />Telephone Number <br />Date Stamped (L)HHS use only) <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 />DHHS 4125 (New 12/16) Reviewed by: <br />Initials Date <br />