Phonak Canada’s Expense Submission Form

"*" indicates required fields

Clinic Name:*

Account Number:*

First Name:*

Last Name:*

Email Address:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phonak Event Name:*

Phonak Event Date:*

Total Expenses ($CAN):*

Total KMs travelled (for those travelling for more than 100 km per one way only):

(return trip and $0.35/km)

Expense Details:*

Please upload a void cheque or direct deposit form or image so we can verify your account details:

Upload image of banking information (JPG or PDF):

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Upload receipt 1 (JPG or PDF):

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Upload receipt 2 (JPG or PDF):

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Comments

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Phonak Canada
80 Courtneypark Drive West, Unit 1
Mississauga, ON L5W 0B3