TAX INVOICE

Invoice to:

EIS Health Ltd: Tower A Lvl 5, 201 Coward St, Mascot, NSW, 2020

Please complete the following data fields completely and correctly to ensure timely payment of the Nurse Winter Vaccination Program funding.

A copy of the tax invoice will be sent to your nominated email address. Please retain a copy of this tax invoice for your records.

Date

General practice details

ABN (must be 11 digits)

Registered for GST?

Entity Name

Business Name (if different to Entity name)

Business Street Address

City

Postcode

State

Email address for remittance advice

Name of nurse(s) utilised under the program

Bank details

BSB (no hyphen)

Bank Account Number

Bank Account Name

Name of Activity: Nurse Winter Vaccination Funding program

Fee payable (including GST)

Please only select $1100 (Part 2) if you have already submitted an invoice for $1100 (Part 1)

Details of applicant

First Name

Last Name

Please type your full name in the text box to indicate that the information provided in this document is correct.