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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:chantelle.kurtz

@

usask.ca@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