Expense Form | ERMEP - Eastern Regional Medical Education Program

Your expenses will not be processed until we have received your completed Evaluation form and your daily Rotation Schedule.

This expense form is not for Community Week students.
Please complete the paper copy you received in your information package.

Thank you.

Personal Information

First and last name *

Address *

Address 2

City/Town *

Province *

Postal Code * Please use the format xxx xxx

Telephone No * Please use the format (xxx) xxx-xxxx

Email *

Rotation dates

Rotation dates from *

Month

Day

Year

Rotation dates to *

Month

Day

Year

Length of rotation (No of weeks) * weeks

Medical School *

Expense Breakdown

Please read the Expense Guidelines before completing this form:

*If you drove to your community placement site in your own personal vehicle you are entitled to $50/week. (Gas receipts are not required)

example:

4 weeks x $50 = $200

5 weeks x $50 = $250

6 weeks x $50 = $300
8 weeks x $50 = $400

*If you took a bus or train, you are entitled to that cost. (Receipts are required)

(from your University to your community placement site and back to the University at the end of the rotation)

No Accommodations: commuted daily - you are entitled to our maximum travel funding of $450.

Please send your bus or train receipts to:

ERMEP

61A Gore Street East

2nd Floor

Perth, ON K7H 1H6

*expenses incurred during the rotation are the learner's responsibility*

Accomodation *

Amount * $

Travel *

Amount * $

GRAND TOTAL * $

Preceptor Information

Preceptor name *

City/Town *

What code is in the image? *

Enter the characters shown in the image.