`

Wakefield Council Social Care Worker Flu Vaccination Voucher Scheme 2016/17

Please return the invoice by the 28th of each month, e-mail to:

Please post the vouchers with a copy of this document to:

Emma Smith, Health Protection Manager

Wakefield Council, Town Hall, Wood Street, Wakefield, WF1 2HQ

Internal Use Only / Invoice Ref: / Payment Code:
Pharmacy Name / Click here to enter text.
Address / Click here to enter text.
OCS Code / Click here to enter text.
Month (Month activity relates to) / Click here to enter a date.
Total number of vaccines delivered (You must list the vouchers numbers below) / Click here to enter text.
Agreed Cost per vaccine / Click here to enter text.
Invoice Total: / Click here to enter text.
This professional service includes an administration of a vaccine and is therefore zero rated for Tax purposes. The vouchers must be submitted or scanned with the invoice and recorded on the next page.
I claim payment to the provision of the service as detailed above and I declare that the information given is true and complete to the best of my knowledge.
Signature (if possible) /
Please print name / Click here to enter text.
Date / Click here to enter a date.
Date of administration / Voucher Number
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Please enter the 4 digits from voucher like 4444.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.
Click here to enter a date. / Click here to enter text.

Page 1 of 2Wakefield Frontline Social Care Worker Flu Vaccination Programme August 2016Page 1