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PRACTICE ENHANCEMENT PROGRAM

6.j Assessor’s Expense Claim Form

Please complete this form and forward to:

Practice Enhancement Program

CPL, Room 5644, D Wing,

U of S - Box 60001, RPO University

Saskatoon SK S7N 4J8

Telephone: (306) 966-7793

FAX: (306) 966-7673 Email

:joanne.peat@usask.ca

Assessor’s Name _________________________ S.I.N. # ___________________

Address where cheque is to be mailed:

Telephone Number ____________________

FAX: _____________________

Name of Physician(s) Assessed Name of City or Town Assessment Date Mileage

______________________ _________________ _____________ ________

______________________ _________________ _____________ ________