Request to Make-up Certification Module

Date of request:

Name:

Title:

Address:

Name of module missed:

Date module given:

Is the above person currently working in the Town Clerk’s Office?

(To be answered by Town Clerk or CEO of town)

If yes to above question, is the person a temporary or permanent employee?

(To be answered by Town Clerk or CEO of town)

Signature of Town Clerk:

OR signature  CEO of town:

State reason module was missed:

Request must be received by the Certification Committee no longer than 8 days after the module was given in order to be considered. Send requests to:

    Lisa Valenti, Certification Committee Chairperson

    E-mail: townclerk@townofnorthbranfordct.com

    Fax: 203-484-6025

    Mail: P.O. Box 287

    North Branford , CT 06471

For Certification Committee:

________ Request is granted.

________ Request is denied due to the following: