Education Claim for Payment Form

This form is to be utilized by anyone seeking payment for services rendered within the Mountain Lakes education program (NYS and AHA courses.) All submissions will be verified by the course CIC or Mountain Lakes staff. Each date worked requires a separate submission. Submission for payment must be submitted no later than two weeks after the date worked. By clicking submit below, you are affirming your submission is truthful and accurate. Please make note of the following pay rates:

NYS CIC (ALS class) - $29/hr

NYS CIC (BLS class) - $27/hr

NYS CLI - $20/hr

Non-Certified Lab Help - $15/hr

PSE Coordinator - $25/hr

PSE Evaluator (NYS CIC or CLI) - $20/hr

PSE Evaluator (non-certifed) - $15/hr

PSE Helper/Patient - $12/hr

AHA Instructor ($25/hr)


Claim for Payment Form

*Full Name:
*Mailing Address:


*Zip Code:
*Phone Number:

*Email Address:
Your CIC or CLI Number (if applicable):

*Date of Work Performed:
*Location of Work/Course:

*Course Type:
*Course CIC or Lead Instructor:

*Type of Work Performed:
*Course Number (if applicable):

*Number of Hours Worked on this Date:
*Dollar Amount of Claim: