Office for Research ABN: 96 237 388 063 P.O Box 5555 Heidelberg 3084 Telephone: 03 9496 4090 Email: Effective of July 2015 Tax Invoice CTN Fee Form Please complete the appropriate Option (1 or 2 or 3). Please note that GST does not apply when requesting a transfer of funds from an internal department (Option 1). GST is applicable for all other forms of payment (Option 2 and 3). Please tick the appropriate boxes where applicable. Please contact the Research Ethics, Office for Research on 9496 4090 if you have any queries Upon payment this document becomes a Tax Receipt. Please retain a copy, as no further receipt will be issued. Project title: <<insert text>> Principal Investigator: <<insert text>> HREC Number: <<insert text>> Project/Protocol No: <<insert text>> Sponsor Name: <<insert text>> Sponsor ABN: <<insert text>> Initial Submission Tick most Study review type Total ($) relevant CTN Application 350 Option 1 For internal projects you must quote a Y3000 or above SPF number (GST not applicable) – Austin Health SPF No: Name of Dept/SPF Expense Classification Charge -see fee schedule 61905 $ Authorised by: Print Name Signature Date Contact Phone No. Option 2 Payment by Cheque or Credit Card (including GST) – CVV # (3#’s) <<insert text>> Cheque (made out to Health”) VISA MasterCard “Austin Credit card number Exp date Name on Card Signature Amount $ Option 3 Payment by EFT (including GST) – Austin Health Banking Details Instructions ACCOUNT NAME: AUSTIN HEALTH Please quote the HREC number (and name of Principal Investigator) when processing the EFT payment details BANK: WESTPAC BANK Submit a copy of the remittance advice together with this form for BRANCH: 216 UPPER HEIDELBERG ROAD, IVANHOE 3079 the EFT to be processed SWIFT NO: WPACAU2S Email a copy of this form with your remittance advice to: BSB: 033286 accounts.receivable@austin.org.au ACCOUNT NO: 120120 FEE STRUCTURE EXPLANATION New Projects For new trials under the CTN scheme, the same fee applies for notifying a multi-site trial or a single site trial, providing the sites involved in the multi-site trial are declared simultaneously on the online CTN form.
Office for Research ABN: 96 237 388 063 P.O Box 5555 Heidelberg 3084 Telephone: 03 9496 4090 Email: Effective of July 2015 Tax Invoice CTN Fee Form Please complete the appropriate Option (1 or 2 or 3). Please note that GST does not apply when requesting a transfer of funds from an internal department (Option 1). GST is applicable for all other forms of payment (Option 2 and 3). Please tick the appropriate boxes where applicable. Please contact the Research Ethics, Office for Research on 9496 4090 if you have any queries Upon payment this document becomes a Tax Receipt. Please retain a copy, as no further receipt will be issued. Project title: <<insert text>> Principal Investigator: <<insert text>> HREC Number: <<insert text>> Project/Protocol No: <<insert text>> Sponsor Name: <<insert text>> Sponsor ABN: <<insert text>> Initial Submission Tick most relevant Study review type Total ($) CTN Application 350 Option 1 – For internal projects you must quote a Y3000 or above SPF number (GST not applicable) Austin Health SPF No: Name of Dept/SPF Expense Classification Charge -see fee schedule 61905 $ Authorised by: Print Name Signature Date Contact Phone No. CVV # (3#’s) <<insert text>> Option 2 – Payment by Cheque or Credit Card (including GST) Cheque (made out to “Austin Health”) VISA MasterCard Credit card number Exp date Name on Card Signature Amount $ Option 3 – Payment by EFT (including GST) Instructions Please quote the HREC number (and name of Principal Investigator) when processing the EFT payment details Submit a copy of the remittance advice together with this form for the EFT to be processed Email a copy of this form with your remittance advice to: accounts.receivable@austin.org.au Austin Health Banking Details ACCOUNT NAME: AUSTIN HEALTH BANK: WESTPAC BANK BRANCH: 216 UPPER HEIDELBERG ROAD, IVANHOE 3079 SWIFT NO: WPACAU2S BSB: 033286 ACCOUNT NO: 120120 FEE STRUCTURE EXPLANATION New Projects For new trials under the CTN scheme, the same fee applies for notifying a multi-site trial or a single site trial, providing the sites involved in the multi-site trial are declared simultaneously on the online CTN form.