Hampshire and Isle of Wight

Primary Care Support England

Application for reimbursement of Professional Defence Union Subscriptions
Name and Address of Practice
Practice Code:
Application by Dr ______for reimbursement of the subscription
costs of a recognised Professional Defence Union in respect of GP Registrar, Dr ______
Declaration by GP Registrar
I hereby confirm I am applying for reimbursement of the subscription in the sum of £ ______
for the period of ______
Signed ______Date ______
Application by Trainer
Signed ______Date ______
Trainer’s Name in Block Letters ______
Please send signed and completed forms by email to Primary Care Support England:
The subject line of your email should state: Practice Code – Name of Practice, County – Type of claim – Trainee’s name

PCSE claim form Jan 2017