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, the Reference Code becomes your unique identifier and appears on remittance advice.
If not provided, a unique identifier will be generated and 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
+ Add Row
Agency Coordinator Name
# of Days
Rate
Coordinator $
Claim Amount $
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 address.
I certify that the information provided in this Pay Claim Form is true and correct.
Submit
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