Trainer Payment Form Please complete the T3 Payment Form in order to process your facilitation payment and be reimbursed for costs expended during trainings. Your check for services rendered will be mailed to you seven (7) business days from submission. Facilitator Information First Name Last Name Mailing Address City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip code Phone Email Training Details Training Date Name of Training CoursePlease select... JFL Core Live Connections Webinar JFL Virtual Core Premium Coaching Session Champion Training Facilitator Training Organization Name Training Location (City and State) Facilitated Role: Please select... Champion Training Facilitator Training Certified Core Trainer Asst. Certified Core Trainer Premium Coaching Reimbursable Expenses No. of Per Diem DaysPlease select... 1 Days 2 Days 3 Days Itemize reimbursable expenses. Include expenses that you paid out of pocket. Airfare Hotel Parking Transportation Please upload ALL receipts of purchases made during training. Also include MEAL receipts. Upload receipts here Submission Date submitted I attest that all information in this form is true and correct to the best of my knowledge. Please check box to submit.Yes Total Amount: $ reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
