Phonak Canada’s Expense Submission Form "*" indicates required fields Clinic DetailsClinic Name:* Account Number:* First Name:* Last Name:* Cheque will be made out to this name.Email Address:* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cheque will be mailed out to this address. Ideally, please provide your personal address as opposed to business.Expense DetailsPhonak Event Name:* Phonak Event Date:* Total Expenses ($CAN):* Total KMs travelled:(return trip and $0.35/km) Total KMs travelled for those travelling for more than 100 km only:(return trip and $0.35/km) Expense Details:*Upload File 1 (JPG or PDF):Max. file size: 24 MB.Upload File 2 (JPG or PDF):Max. file size: 24 MB.Terms & Conditions:*You acknowledged that all information you submit to us is truthful and accurate. I agreeEmailThis field is for validation purposes and should be left unchanged. Phonak Canada80 Courtneypark Drive West, Unit 1Mississauga, ON L5W 0B3