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Angus S. King, Jr.

Governor

State



Kevin W. Concannon

Commissioner

 

Bureau of Elder and Adult Services

442 Civic Center Drive, 11 State House Station

Augusta, ME  04333-0011

 

PCA Training Cost Reimbursement Form

 

Agency:                  __________________________________

Address:                 __________________________________

                  __________________________________

                  __________________________________

 

Phone:                              __________________________________

Fax:                              __________________________________

Contact Person:                              __________________________________

PCA Reimbursement approved: _________ (# PCA x $125)

# PCAs: ____

 

PCA Name SSN Attendance Dates Class Location Certified PCA
Training
Program		 Instructor Passed
Test		 Passed
Demo
Yes No Yes No
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