Topsham, Maine 04086

STAFF COURSE COMPLETION REPORT

(Submit one form for each course for which advance payment was received)

Name____________________________________________________________________________

Mailing Address____________________________________________________________________

I have successfully completed the following course:

(Transcript of the grade received or Certificate of Completion from the instructor is attached)

Course ID/

Name_____________________________________________________________________________

Institution/

Agency____________________________________________________________________________

Course Type: ____ Graduate ____ Undergraduate ____ CEU ____Other (specify)

Credits Earned________________________

______________________________________ __________________________________

Employee Signature Date