Notebook Reimbursement – website applicationPage | 1
This form (“Attachment 3”) is to be completed by former Victorian State Government Teachers and Principals who have not received the letter and its attached formsrequesting their bank or credit union account details in the mail.
To be eligible to receive reimbursement of your notebook deductions you must have been employed in the Victorian State Government School system at some time between 1 July 2009 and 1 November 2015 and participated in the Notebook (Laptop) for Teachers program after1 July 2009.
All fields are required to verify your identity and to make the payment to your bank or credit union account.
- This form may be completed online by clicking on the next field or by using the Tab key to move through the required fields. The form may also be printed and completed by hand. Please print clearly using BLOCK letters.
- Retain a copy of the completed Attachment for your records.
- Do not submit multiple forms.
- Print, sign and return the completed formto:
Payroll Services,
Department of Education and Training,
GPO Box 4367,
Melbourne 3001
ORprint, sign, scan and email to . Use one method only.
- Further information and updates regarding payments will be provided at:
Employee Information
Employee ID(can be found on past payslips and other Departmental documentation)
Employee Name
Date of Birth
Date of first employment with the Department
Last date of employment with the Department
Employment History (from 2009) (List the Victorian Government Schools/Work Units you were employed at between 2009 and the date you ceased employment with the Department.) CRT employment is not relevant.School Name/Work Unit
/ Year(s)Bank/Credit Union Details(Your notebookreimbursement will be paid into this account).
Bank Name
BSB
Account Number
Account Name
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Address Details during your employment(This address will be used to send your Pay As You Go (PAYG) Summary in July unless a new address is provided below)
Street Address
Suburb/ Town
Postcode
New Address Details(Update this section ONLY if your address has changed OR you would like your PAYG Summary to be sent to a different address to the one provided above)
Street Address
Suburb/ Town
Postcode
Contact Details (In case we need to contact you)
Email address
Business hours contact phone number
Authorisation (before signing and returning this form – double check ALL details are correct.)
I was employed in the Victorian State Government School system between 1 July 2009 and 1 November 2015 and participated in the Notebook (Laptop) for Teachers program.
I confirm the details provided above are true and correct.
Use the banking details above to make the laptop reimbursementplus interest to me.
I would like my PAYG to be mailed in July to the addressprovided above.
Signature:...... Date:......
Application for Notebook Reimbursement - Website