ASE Certification Test Reimbursement FormThe following documents must be included with this form in order to receive reimbursement:

• Copy of your ASE Certification Score Report• Copy of confirmation of payment (with amount listed) for ASE Certification

Name(s) of ASE Test(s) successfully completed:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Date and Location Test was taken:

___________________________________________________ Amount Paid for ASE Certifications: $______________

Name _____________________________________________ Member ID # _________________________________

Home Address ______________________________________________________________________________________

Phone Number ______________________________________ Email Address ________________________________

Employed By _______________________________________________________________________________________

All members may receive 3 reimbursements per calendar year for ASE Certification. Claims can only be submitted for the curent year and must be made within 90 days of test completion. Reimbursement is not allowed for pre-test study aids, test prepartion courses, workshops, travel expenses, etc. Technician can not be reimbursed if reimbursement program is available through their employer.

I authorize that I have successfully completed the ASE Certification that I am requesting reimbursement for. Further, this request falls within the stipulations listed above.

______________________________________________________ ______________________________Signature Date

Please Mail Form & documents to: AASP-PA, 2151 Greenwood Street, Harrisburg, PA 17104 or fax to (717) 564-5215