DATE AND LOCATION OF MEETING NAME OF REFEREE NAME AND ADDRESS OF EMPLOYER REFEREE’S TELEPHONE NUMBER EMAIL REFEREE’S CLAIM DETAILS: DATE OF REIMBURSE AMOUNT RECEIPT DETAILS (e.g. travel, (delete as CLAIMED INCLUDED accommodation) appropriate) HONORARIUM or 0 n/a n/a Honorarium for evaluation referee/employer 900 € € HOTEL COSTS Yes/No referee/employer ECONOMY TRAIN Yes/No referee/employer FARE/FLIGHT OTHER COSTS Yes/No referee/employer PLEASE STATE THE CURRENCY IN WHICH YOU WISH TO RECEIVE THE REIMBURSABLE AMOUNT. ALL CLAIMS WILL BE PROCESSED IN EURO UNLESS SPECIFIED OTHERWISE BANKING DETAILS: ACCOUNT ACCOUNT REFEREE’S EMPLOYER’S NAME OF ACCOUNT HOLDER (as registered with the bank) ADDRESS OF ACCOUNT HOLDER (as registered with the bank) CONTACT PERSON FOR THE Name: ACCOUNT HOLDER n/a Tel: (e.g. company financial contact) Email: BANK NAME FULL BRANCH ADDRESS (P.O. BOX not acceptable) Account number UK: Bank code Swift address code EUROPE: IBAN number US: A.B.A/routing code Please tick if the referee is not registered for VAT. If payment is through Employer, please tick if the employer is not registered for VAT.
DATE AND LOCATION OF MEETING NAME OF REFEREE NAME AND ADDRESS OF EMPLOYER REFEREE’S TELEPHONE NUMBER REFEREE’S EMAIL CLAIM DETAILS: AMOUNT CLAIMED RECEIPT INCLUDED DATE OF DETAILS (e.g. travel, accommodation) REIMBURSE (delete as appropriate) HONORARIUM 900 € or 0 € n/a n/a Honorarium for evaluation referee/employer HOTEL COSTS Yes/No referee/employer ECONOMY TRAIN FARE/FLIGHT Yes/No referee/employer OTHER COSTS Yes/No referee/employer PLEASE STATE THE CURRENCY IN WHICH YOU WISH TO RECEIVE THE REIMBURSABLE AMOUNT. ALL CLAIMS WILL BE PROCESSED IN EURO UNLESS SPECIFIED OTHERWISE BANKING DETAILS: REFEREE’S ACCOUNT EMPLOYER’S ACCOUNT NAME OF ACCOUNT HOLDER (as registered with the bank) ADDRESS OF ACCOUNT HOLDER (as registered with the bank) CONTACT PERSON FOR THE ACCOUNT HOLDER (e.g. company financial contact) n/a Name: Tel: Email: BANK NAME FULL BRANCH ADDRESS (P.O. BOX not acceptable) UK: Account number Bank code EUROPE: Swift address code IBAN number US: A.B.A/routing code Please tick if the referee is not registered for VAT. If payment is through Employer, please tick if the employer is not registered for VAT.
Form6b.docx