Office for Research – GST Compliant Tax Invoice
Amendment Payment Form
ABN 73 802 706 972
Date: / Melbourne Health Local HREC No: /Principal Investigator:
/Ethics Amendment Fee: / Ethics Review
(GST incl.) / Governance Review
(GST incl.)
Commercially sponsored projects:
Protocol amendments; substantial PICF changes* / $880 / $660
Admin changes; updated IB; addition of investigator only** / $220 / $220
Addition of a site to an existing clinical trial*** Enter number of sites: / $550 per site (fee capped at $2,200) / NA
All other projects / No Fee / No Fee
Enter total amount payable* à
PLEASE NOTE: Melbourne Health will charge either an Ethics review fee or a Research Governance review fee, in accordance with the above schedule, but not both.
* Substantial PICF changes include changes to the PICF due to updated safety information and/or protocol amendments. This does not include administrative changes to the PICF such as addition of investigators or syntax/typographical amendments.
** Admin/IB changes will not incur a charge if submitted in conjunction with a protocol amendment or substantial PICF changes. For example, if a protocol and an IB are submitted together, the ethics review fee for the amendment will be $880 only.
*** These charges are on top of any other amendments. For example, if a protocol, IB and 2 additional sites are submitted together, the ethics review fee for the protocol/IB will be $880 plus $1100 for the 2 additional sites ($550 x 2).
Company Name & Address: /Company ABN:
/Contact Name:
Email:
PAYMENT METHODS
Cheque (Attach cheque to this form)
Contact Name: /Cheque Number:
/Cost Centre Transfer (internal only – remember to exclude GST in the total amount payable )
Cost Centre Number:
/ /Cost Centre Manager (Print Name):
/Cost Centre Manager (Signature):
/ /Ex-GST Amount:
/$
Credit Card
Card Type (only listed cards accepted) /Visa MasterCard Bankcard
/ Expiry Date:Credit Card Number:
/ /Card Holder’s Name:
/Indicate maximum transaction amount if split payment is required
/ Card Holder’s Signature:Electronic Funds Transfer (EFT)
Instructions1. Submit a copy of the Remittance advice together with this form in order for the EFT to be processed
2. Email a copy of this form with your Remittance Advice to . / Melbourne Health Banking Details
Bank: NAB
Branch: Level 2, 151 Rathdowne Street, Carlton, VIC 3053
Account: MHS- OPERATING
A/C No: 122931890
BSB: 083-170
Date of Transaction: /
Transaction Number Details:
/Finance Service Use Only
Cost Centre / AC / Tax Code / Receipt Number / DateMRM-R1727 / 58101 / G1 / ______/______/______