Claim Form for Interview, Travel & Subsistence Expenses

Invoice No: YHD Claim Form for Interview, Travel & Subsistence Expenses for Specialty Recruitment in the Yorkshire & the Humber Deanery o Receipts must be attached for all travel and subsistence claimed (except for mileage) o Where there is no receipt a full written explanation must be attached o Please complete both pages of this form o Claims must be made within 3 months of the interview date

Please complete this form in BLOCK CAPITALS. Failure to do so may delay payment

First name Surname Title & initials

ADDRESS & TELEPHONE NUMBER

Street & Number

County Postcode

Daytime Contact Number E-mail address

INTERVIEW DETAILS

Specialty Entry level

Venue Interview Time

Date of Interview Vacancy Reference No

PAYMENT DETAILS Payment will be issued by NHS Shared Business Services, Phoenix House, Topcliffe Lane, Wakefield, WF3 1WE. Telephone Number; 0303 123 1177

PLEASE NOTE ALL PAYMENTS WILL BE PAID BY BACS DIRECTLY INTO A BANK ACCOUNT.

Payee (if different from above):

Bank Sort Code: - - Bank /Building Society Number:

Name of Bank:

CLAIMANT DECLARATION

I declare that the expenses claimed hereunder were necessarily incurred by me in attending the Appointment Committee, and are in accordance with the conditions governing the payment of travelling expenses.

Signed Date

D:\Docs\2018-04-05\04ac404464e9bad8debb72cf5e1dc31b.doc o All columns must be completed if applicable to your journey o Please read the guidance notes you obtained along with this claim form very carefully. The Deanery reserves the right to reimburse the cheapest option wherever relevant. o Please seek prior written approval wherever necessary. Details Of Claim

Subsistenc Receipts Journey times Car Fares Date Journey details e mileage (please Start Finish £ P £ p tick)

For office use only

Please return your claim to the locality office where you attended interview:

South Yorkshire/Sheffield West Yorkshire/Leeds North & East Yorkshire and North Lincolnshire/Hull Yorkshire & the Humber Deanery Yorkshire & the Humber Deanery Yorkshire & the Humber Deanery South Yorkshire Locality Office West Yorkshire Locality Office N&E Yorkshire and North Lincolnshire Locality Office Don Valley House Willow Terrace Road Ground Floor, Block A Savile Street East University of Leeds Willerby Hill Business Park Sheffield Leeds Willerby S4 7UQ LS2 9JT Hull HU10 6FE ------

CERTIFICATION OF ATTENDANCE (FOR OFFICE USE ONLY)

I have checked this claim and am satisfied that the claimant attended an interview according to the information given and that the final total of expenses indicated below is correct.

Signed: Date: Name:

TOTAL EXPENSES £ p

Transport expenses

Subsistence

Miscellaneous expenses

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