TRAVEL EXPENSE AND HONORARIA
CLAIM FORM
2015-16
Please Return To: Doctors Nova Scotia
Telephone: 902-468-1866
25 Spectacle Lake Drive
toll free: 1-800-563-3427
Dartmouth, NS B3B 1X7
Fax: 902-468-6578
Web Site:
NAME:____________________________________________
ID#
ADDRESS: ________________________________________
________________________________________
GL#
POSTAL CODE: _________
TELEPHONE:___________
Council/Meeting Name:_____________________________________
Working Group Name: _____________________________________
For office use only
Location:
_____________________________________
Meeting Date:________________
Start and Ending Time: _______________
Transportation Costs:
Air Fare (Economy)
$___________
Car Mileage ($.50/km)
____________kms
___________
Taxis
___________
Car Rental
___________
Other (please specify)__________________________
___________
Maintenance Costs
Hotel
___________
Meals
Breakfast
Lunch Supper (Receipts Please)
___________
(see reverse for guidelines)
Other Expenses Claimed (Please Specify)
_________________________________
_________________________________
___________
Total Expenses Claimed
$ __________
(Please Attach All Supporting Receipts
Date:__________________________________ Signature:________________________
THIS FORM MUST BE COMPLETED & RETURNED WITHIN 30 DAYS OF TRAVEL
For Office Use
Cost Centre______________________
Honoraria Days___________________
Departmental Approval ____________
Payment Approval_________________
Doctors Nova Scotia