BHWET-ENC Professional Track Application

Non-Participant Mobile Health Training Program (MHTP) Reimbursement Form

Please fill out this form if you are NOT a student enrolled in the MHTP/AHEC Scholars program, but you have been told to apply for reimbursement through the program.

By accepting reimbursement, you consent to follow-up on your employment status 1-year after graduation.

First name:

Last name:

School Email Address:

Personal Email Address:

Preferred Phone Number:

Student NetID (if MSU), combines numbers and letters (a12b345):

Birthdate (mm/yyyy):