HNSW State Champs Officials Reimbursement Form

PERSONAL DETAILS

Name*

Phone Number*

Email Address*

Event*

Location*

Position held at event*

Date(s)*

REIMBURSEMENT OF KM

TRAVEL = $0.35/km (minimum 10km) E.G - Sydney Olympic Park > Moorebank > Sydney Olympic Park Total Kms = 45.2 Cost = $0.35 x 45.2 = $15.82

Details of Reimbursement (From > To = Total KMs)

Total Amount

MEALS - Up to $40/day*. Breakfast/Lunch/Dinner only

Meals = Up To $40 per day Breakfast - $10 per day Lunch - $10 per day Dinner - $20 per day You are unable to claim any meals that are provided by Hockey NSW. i.e Vouchers,Included at Accommodation.

Details of Reimbursement (Meals)

Total Amount

OTHER

Details of Reimbursement (Other)

Total Amount

BANK ACCOUNT DETAILS & TOTAL AMOUNT

BSB Number*

Account Number*

Name of Account*

TOTAL AMOUNT (Travel + Meals + Other)*

Have you changed your bank details since your last Hockey NSW reimbursement?*

SIGNATURE - I acknowledge that the information obtained in this form is true and correct as of the date mentioned.

Signature (Print Name)*

Date*

RECEIPTS

Please upload any receipts.

Choose file...

Max 5MB

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