Leave requested (must be applied for at least 6 weeks prior to event)

Please list the exact date(s) on which you require leave:*

Total number of days*

Course details

Course name*

Course Location*

Describe how course fits into your PDP *

Other comments

Expenses

Transport

Estimated Travel Cost

Course/Conference fee*

Accommodation

Subsistence

Are you receiving grant from any other source?

YesNo

Please explain

Total Amount Claimed (please deduct grant amount if applicable)*

Final details

Trainer's email*

Rotamaster's email*

Even if absence doesn't affect the Rota, some Trusts would like you to copy them in anyway so that they are aware of the reason for your absence so please do check...

Name of Doctor Covering

Cover Contact Email

FALSE DECLARATIONS ARE BREACHES OF TRUST AND GMC PROBITY

I confirm that by requesting funding I authorise the NW School of Psychiatry to receive progress reports or concerns from the Course providers

I confirm the facts on this form are true

Please note this applicaiton will be submitted to your TPD for approval. HENW will forward you the appropriate claim forms.