PERSONAL DETAILS
First Name	:	Surname:
Street Address	:
Suburb	:	State:	Post Code:
Phone	:	Fax:
Email	:
REIMBURSEMENT DETAILS *Please insert YOUR Account details
BSB Number	:	Account Number:
Account Name	:
Code (office use)	Description (office use)	Details e.g. MDRAP – Foundation Module 1	Total
6-7082	Course/Conference Cost	$
6-7082	Course/Conference Cost	$
6-7082	Course/Conference Cost	$
6-7082	Course/Conference Cost	$
6-7082	Course/Conference Cost	$
TOTAL	$

CLAIMANT
Signature:	Date:

DISCLAIMER
Receipts, as evidence of payment, are required under Government Funding Guidelines and Health Workforce Queensland’s Financial Assistance Policy. The Agency does not accept any third-party claims or reimbursements with all financial assistance being disbursed directly to individuals upon receipt of a claim form with associated documentation as indicated on the appropriate form.
OFFICE USE ONLY
Job Code	:	190L410	Residual Funds Available:	$
Liability Account	:	2-7069	Confirmed by:
TOTAL approved	:	$	Tax Code: N-T:
Name of Authoriser	:
Signature	:	Date: