Finance Dept

PO Box 16967

14-17 George Road

Edgbaston

Birmingham

B16 6TT

Tel: 0121 371 7477

APPLICATION FOR REMOVAL AND ASSOCIATED EXPENSES

Confidential

PLEASE PRINT IN BLOCK CAPITALS AND COMPLETE ALL PARTS (1-5)

  1. Surname:

Dr/Mr/Mrs/Ms

Forename:

Current Address:

Postcode:

Is this address temporary or permanent?

If temporary, please state circumstances:

Address for correspondence (if different)

Is it your intention to move Permanentlyinto the area to take up your rotational post Yes/No

(The above question needs to be answered before we can process your claim any further)

Telephone number – Home:Work:

Mobile:

Marital Status (Single, Married, Single with equivalent responsibilities)

Full name of spouse/partner

No. of children, and age:

Employment / New Post / Previous Post
Authority
Hospital
Department
Title of Post
Grade
Whole/Part time
(sessions hours)
Salary at appointment/termination
Date of appointment / termination / Appt:
Term:

2.Present accommodation (circle one only)Old AreaNew Aera

Hospital accommodation (room/flat) X X

Owner Occupied X X

Furnished accommodation (room/flat/house) X X

Unfurnished accommodation (more than 2 rooms X X

-excluding kitchen and

bathroom)

3Have you received removal expenses within the previous two year period?YES/NO

4.Please confirm whether your spouse or partner can claim removal and

Associated expenses from another source.YES/NO

If yes, please provide full details

  1. Declaration to be completed by applicant:

I confirm that the expenses I am claiming have not or will not be recovered in full or part from another source.

I, hereby make formal application for assistance towards

removal / travel expenses incurred by me,

from (area):To (area):

Following my appointment in the grade of

Undertake to remain in the Trust’s employ for a minimum of two years. (this does not apply to Junior Doctors and Dental Staff)

(a)Two Years in the case of married officers or single officers with equivalent responsibilities.

(b)One year in the case of other practitioners

Unless circumstances occur during the period which the Trust accepts as serious enough to justify any release from this undertaking I am aware that if the undertaking is otherwise broken by me I may be called upon to refund the whole or part of the sum paid to me as removal / travel expenses.

Signature of Applicant: Date:

Office use only

  1. To be signed by medical staffing / HR Manager / Divisional Director: Should you be on the Oxford

Deanery Rotation Programme, then you need to forward your application to the address at the top of the form for authorisation – Failure in doing this will delay the process of re-inbursement.

Signed:Print name:Date:

Contract dates:

Trust / From: / To: / Compulsory Resident Y/N / Contracted Hours
Contract 1
Contract 2
Contract 3
Contract 4
Contract 5

Any limitations on removal expensesYES/NO

If ‘yes’ please specify

Maximum £

7.Approved by:

HR Director:

Date:

On completion, this application should be forwarded to the Relocation Officer at the address shown above.