Expense Form

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
Please use the format xxx xxx
Please use the format (xxx) xxx-xxxx
Rotation dates
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)
        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:
     61A Gore Street East
     2nd Floor
     Perth, ON   K7H 1H6
*expenses incurred during the rotation are the learner's responsibility*
Preceptor Information
Enter the characters shown in the image.