Resident & Student - Placement Pre-Approval Form

Yukon Resident & Students

Placement Pre-Approval Form
Any questions can be directed to:

Fund Manager, Yukon Medical Association
5 Hospital Road, Whitehorse, YT Y1A 3H7
funds@yukondoctors.ca
Role

Other
Name

First NameLast Name
Preferred E-mail Address
Your E-mail Address
Preferred Contact Number
Format: (000) 000-0000.
Estimated start date elective booked

MonthDayYear
Date
Estimated rotation end date

MonthDayYear
Date
Any extra info or dates if needed (optional)
Program Requirements:
- apply to the program for reimbursement within three months of the date of completion of the learning period in Yukon;
- acknowledge and disclose all financial assistance received for the same eligible expenses and only apply for reimbursement for expenses not already covered;
- do not submit expenses related to the travel for a spouse, family members or dependents;
- submit a reimbursement claim detailing all travel related expenses including photocopies, flatbed or sheet-fed scans of actual receipts and documents to set up for payment via direct deposit;
- keep their original receipts for income tax purposes and send copies with the reimbursement claim; and
- not apply for reimbursement of expenses for vacation time in the Yukon prior to or after completing a learning period.
Reimbursement from other jurisdictions for the same expenses for the same time period could result in fraud charges.
I certify

Estimated Expenses for Pre-approval
Estimated Travel Expense
Airfare will be reimbursed based on advance-booked, economy airfare, Flex Fare or equivalent, the most direct routing + first checked bag fee per flight.
Estimated Accommodation
Rent is reimbursable, with proper receipts.
Estimated other expenses
Explanation of other expenses
Total Estimated Expenses
If you have reached the maximum allowable claim amount, reimbursement will only be provided up to the applicable program maximum.
Add any additional details or information if needed.
File Upload Tip: If using a phone, for best quality, take a photo with your phone camera first, then upload from your photo library. This dramatically reduces blurry receipts. Please upload any receipts or documents here.

Cancelof
Payment by direct deposit
YMA Direct Deposit Form
Signature
Date signed

MonthDayYear
Date
Terms and Conditions: Requirements and eligibility criteria are subject to change. Always download the latest version from www.yukondoctors.ca Any feedback on this or any of the YMA forms welcomed and appreciated to funds@yukondoctors.ca
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Yukon Resident & Students