Please Type Or Complete in BLOCK CAPITALS for HEEKSS Use Only

INVOICE

ALL FORMS MUST BE TYPED AND NOT HAND WRITTEN. THEY MUST ALSO BE COMPLETD IN FULL. FAILURE TO DO THIS WILL RESULT IN PAYMENT DELAYS OR NON PAYMENT

Please Type or complete in BLOCK CAPITALS For HEEKSS Use Only

Invoice Number / 16ASK530-CPD -
Invoice Date / / / /
PO Number / XXSSMITH
Practice Name / FAO
Address Line 1 /
Address Line 2
Address Line 3
Town/City
Post Code
Health Education England – T73
KSS LETB
T73 Payables F485
Bank Account Number / Bank Account Sort Code / PAYABLE TO / 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.

Total Value of the Claim / £

Please fill in the breakdown of the claim on the following page

Details of the claim

Training practices may claim for each GP Trainer CPD grant on one claim form provided that they meet the criteria and that their names/signatories are listed below.
Criteria for eligibility for Trainer CPD funding
an approved trainer with effect from 1 July 2016.
an active Trainer during the period August 2016 – July 2017. Trainers who have advised that they will be resigning during this period will receive a pro rata level of the CPD grant.
have up to date Equality and Diversity Training (E&D) – this is mandatory for all GP Educators and valid for a 3 year period.
EVENT/ACTIVITY / GP TRAINER DDRB (CPD) GRANT 2016/17- £750 per Trainer
PRACTICE NAME
TRAINER NAME (1) / Trainer signature:
TRAINER NAME (2) / Trainer signature:
TRAINER NAME (3) / Trainer signature:
TRAINER NAME (4) / Trainer signature:
TRAINER NAME (5) / Trainer signature:
TRAINER NAME (6) / Trainer signature:
TOTAL CLAIMED / Amount Claimed
Fee Claimed No. of GP Trainer CPD Grants= ____ x £750
(Total amount claimed – should match value box on front page) / £
Claimant Declaration: I declare that the claim above are in accordance with the conditions governing the payment. I understand that that I am responsible, where appropriate, for declaring this income for tax purposes.
Name:
Role of claimant (eg Practice Manager/Business Manager):
Signed: Date:

This form then needs to be returned to the LETB for authorisation before submission to SBS

Authorised By:
Name:Sue Smith
Position:Primary Care Placements Manager
Department:General Practice/Primary Care
Contact Number:
Signed: Date: