FedUni – Professional Experience Pay Claim Form

Agency Details

Agency Name Management Body (if applicable) Address Postcode Australian postcodes are 4 digits. Administrator Phone Number Pay Claim Reference Code (optional)

Payment Schedule (Reference)

Notes

Payment Reference Code is optional; if provided it will become your unique identifier and reflect on our remittance advice. If left blank, a unique identifier will be assigned to your payment.
Select the applicable rate based on the year the placement was completed.

Claim Details

Add a row for each mentor / student placement claim.

Mentor Name	Student Name	Placement From	Placement To	# of Days	Rate	Amount $	Action

Agency Coordinator Name	# of Days	Rate	Coordinator $	Total Claim $	Total incl. GST(10%)

Agency Authorisation

Authorising Name Date Agency Email Required. A confirmation copy of this Pay Claim will be sent to this email address. I certify that the information provided in this Pay Claim Form is true and correct.

By submitting this form you confirm that all information provided is true and correct. A confirmation copy will be sent to the email address provided.