Important Please read instruction

before completing the expense claim form

1)Please complete the form electronically and print it outsingle sided. Please note there is no facility to save this form on the website

2)Please complete all mandatory fields which are shaded green as completion of the form is prevented if any are left blank. The template is formatted to only print out on A4 portrait

3)Please have all receipts photocopied onto A4 and attach to the printed expense claim form. Do not send in original receipts

4)This signed invoice must be submitted within 28 days of your interview date. Claims received after that date will not be processed

Any queries please email to

with SUBJECT title “travel expenses claim”. You Must include the date of the interview and the speciality, otherwise we will be unable to direct your query.

failure to follow these directions will result in your claim being rejected.

INVOICE / BUDGET CODE: J47015-7273-M1280 /
Surname / FOR OFFICE USE ONLY
First Names / Invoice Number
Address 1 / Invoice Date
Address 2 / Specialty
Address 3 / PO NumberAttn Of
Town/City
Post Code

Invoice To:
Birmingham SHA
Q34 Payables 7305
Phoenix House
Topcliffe Lane
Wakefield
WF3 1WE
Bank Account Number / Bank Account Sort Code / account HOLDER name / Swift code
(overseas only) / E-mail address for
remittance advice

NOTE: PLEASE ENSURE BANK DETAILS ARE ENTERED. FAILURE TO ENTER THESE DETAILS WILL RESULT IN THE REMITTANCE BEING MADE BY CHEQUE, WITH INEVITABLE PAYMENT DELAYS.

qty / description / line total
1 / CLAIM FOR INTERVIEW AND TRAVEL AND SUBSISTENCE EXPENSES FOR CT or ST 1/2/3/4 RECRUITMENT 2012/13.
EVENT VENUE: EVENT DATE: / £
  • Receipts must be attached for all amounts claimed
  • This Invoice form must be submitted within 28 days of your interview. Any received after this period will not be processed
  • Maximum amount payable is £100.00

TOTAL VALUE / £
Claimant Declaration: I declare that the expenses claimed hereunder were necessarily incurred by me in attending the Stage 2 Assessment Centre and are in accordance with the conditions governing the payment of travelling expenses
Signed: Date:
Certification of Attendance: I have checked this claim and am satisfied that the claimant attended an assessment according to the information given and that the Total claimed is correct.
Signed: Date: Name:

Terms & Conditions

General – The amounts claimed are in accordance with NHS regulations and are in respect of expenses actually and necessarily incurred whilst engaged in the business stated.

Tax – The claimant is responsible for any tax that may be payable on any monies received in relation to this claim.

DETAILS OF CLAIM – Please attach all receipts otherwise claim will not be paid

FOR LAY CHAIR/PANEL MEMBER ONLY– WERE YOU PRESENT FOR (PLEASE TICK): -

HALF DAY / FULL DAY
ARCP / TRAINING DAY / SHORTLISTING / INTERVIEW
OTHER (e.g. Deanery Business)

FOR ALL CLAIMANTS

ALL COLUMNS MUST BE COMPLETED IF APPLICABLE TO YOUR JOURNEY

Please read the guidance notes you obtained along with this claim form very carefully. The deanery reserves the right to reimbursethe least costly option wherever relevant. Please seek prior written approval wherever necessary

Date / Journey Details
(From/To)* / Journey Times / Car Mileage
@24p/m / Fares / Subsistence / Receipt
(Please tick)
Start / Finish / £ / P / £ / P
For Office use only
*please specify if origin of travel is different from home address

SECTION 3 - CLAIMANT DECLARATION

I declare that the expenses claimed hereunder were necessarily incurred by me in attending the stated event and in accordance with the conditions governing the payment of travelling expenses

SIGNED / DATE
Specialty
INVOICE NUMBER