Sample Claim Form For Terminal Expenses and Hazard Allowance

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					                          Sample Claim Form
              For Terminal Expenses and Hazard Allowance

Name:                            Signature: ____________________

Month/Year:                      Date:

GTA No.:


Terminal expenses:

 No.           Destination        Dates         Mode of       Approved
                                               Transport
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.
 10.


HAZARD ALLOWANCE

 No.         Hazard Location      Dates       No. of Days      Amount
                                                              Approved
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.
 10.



Approved by:

Signature:     _________________________________

Date: