BLACK COUNTRY SUPPLY SERVICE TEACHER CLAIM FORM

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					                                               BLACK COUNTRY SUPPLY SERVICE TEACHER CLAIM FORM


Deadlines for receiving claim forms at the Black Country Supply Service are by the 5th day of each month. Late claim forms will delay payment
by at least one month

   1. Name………………………………………………..                                              4. DOB…………………………………………………..

   2. Employee No……………………………………………...                                       5. Are you in the teacher s pension scheme? YES/NO

   3. Address…………………………………………………………………………………………………………………………………………………

To be completed by the supply teacher                                               To be completed by head teacher/supply staff co-ordinator
       Date              School at which work has been          Number of hours         Signature to authorise            Print name
                                   undertaken                      worked             number of hours worked




                    Total hours worked:                                             Signature of supply teacher:

To ensure prompt payment of this claim, the Black Country Supply Service must hold your current bank details
All claim forms to be sent to: Black Country Supply Service Team, Wolverhampton Science Park, Glaisher Drive, Wolverhampton. WV10 9RU