<p> 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</p><p>Please complete this form in BLOCK CAPITALS. Failure to do so may delay payment</p><p>First name Surname Title & initials</p><p>ADDRESS & TELEPHONE NUMBER </p><p>Street & Number </p><p>Town</p><p>County Postcode</p><p>Daytime Contact Number E-mail address </p><p>INTERVIEW DETAILS </p><p>Specialty Entry level</p><p>Venue Interview Time</p><p>Date of Interview Vacancy Reference No</p><p>PAYMENT DETAILS Payment will be issued by NHS Shared Business Services, Phoenix House, Topcliffe Lane, Wakefield, WF3 1WE. Telephone Number; 0303 123 1177</p><p>PLEASE NOTE ALL PAYMENTS WILL BE PAID BY BACS DIRECTLY INTO A BANK ACCOUNT.</p><p>Payee (if different from above):</p><p>Bank Sort Code: - - Bank /Building Society Number: </p><p>Name of Bank: </p><p>CLAIMANT DECLARATION </p><p>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. </p><p>Signed Date</p><p>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</p><p>Subsistenc Receipts Journey times Car Fares Date Journey details e mileage (please Start Finish £ P £ p tick)</p><p>For office use only</p><p>Please return your claim to the locality office where you attended interview:</p><p>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 ------</p><p>CERTIFICATION OF ATTENDANCE (FOR OFFICE USE ONLY)</p><p>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.</p><p>Signed: Date: Name: </p><p>TOTAL EXPENSES £ p</p><p>Transport expenses</p><p>Subsistence</p><p>Miscellaneous expenses</p><p>Total</p><p>D:\Docs\2018-04-05\04ac404464e9bad8debb72cf5e1dc31b.doc</p>