Your company name:
     Trading as:                                                                                            Page 1 of 2
                                     Influenza reimbursement  TAX INVOICE
     To:                   Immunisation team, Ministry of Health, PO Box 5013, Wellington, 6140
     Invoice date                       Invoice No:                              GST No:                    Your Ref: 
     Contact Name:                                                 Phone:                      Post code:
     Street address:                                                                            Town/City:
     Postal address:      e.g PO Box
            Provider or Payee No:                              Please provide this if you have been previously paid directly by 
                                                                                      the  MInistry
                          Details of claim                           Vaccination cost               Vaccination cost 
                                                                       including GST                 excluding GST
              eg           Influenza    Employee name                                   $35.00                      $30.43
                          Vaccine
              eg           Influenza    Employee name                                   $40.25                      $35.00
                          Vaccine
               1                                                                         $0.00                       $0.00
               2                                                                         $0.00                       $0.00
               3                                                                         $0.00                       $0.00
               4                                                                         $0.00                       $0.00
               5                                                                         $0.00                       $0.00
               6                                                                         $0.00                       $0.00
               7                                                                         $0.00                       $0.00
               8                                                                         $0.00                       $0.00
               9                                                                         $0.00                       $0.00
              10                                                                         $0.00                       $0.00
                                                                                                   Subtotal         $0.00
                                                                                                  Total GST         $0.00
                                                                                  TOTAL PAYABLE (incl GST)          $0.00
                                                                                         Page 2 of 2
                                                        Bank           Branch    Account Suffix
            Bank account details for payment:
        If you have not been paid directly by the Ministry before, please also submit proof of these bank account details
    By returning this form you understand that:
    ·      the Ministry of Health will use the information in this application form in a manner consistent with the Privacy Act 1993 
           to process claims for funding to support influenza vaccination for health and disability sector employees. 
     ·      the information in this application form will be held securely by the Ministry and will be kept confidential except when 
                                        required to be disclosed by law.
     By returning this form you certify that:
    ·      I/we have complied with the conditions (if any) of my/our authorisation to claim for funding to support influenza vaccination for health 
                                and disability sector employees by the Ministry of Health
    ·      I/we are not claiming for any employee who has been the recipient of an employer-funded influenza vaccination in this workplace (not 
                               including one reimbursed by the Ministry of Health in 2020)
      ·      the information contained in this form is true and correct.