Emergency contraception reimbursement
This form allows you to anonymously apply for reimbursement following purchase of emergency contraception (i.e. the morning after pill) for yourself or your partner.

To use the scheme, fill in the date on the receipt, the amount to be reimbursed, and your bank details below. You get to choose a linking number as well, which we will use with the date to match your receipt to this form.

You will then need to leave the receipt in Jamie Beacom's or Helen Hailes' pigeon hole at Holywell Manor, or post it there, for the funds to be transferred.

If you have any questions about the scheme, or are having problems with the form, email Jamie Beacom (jamie.beacom@balliol.ox.ac.uk - MCR Welfare Officer) or Helen Hailes (helen.hailes@balliol.ox.ac.uk - MCR Welfare Officer). All correspondence will of course be kept confidential.

Please note that we are only able to directly reimburse UK accounts, if your account is based elsewhere we can offer cash reimbursement - please contact Jamie to arrange this.

You should be reimbursed within 2 weeks, contact Jamie or Helen if you do not receive money by a month after filling in this form.

Linking number *
Pick a number between 1-100, put it here and also write it on your receipt. This will help us to match your receipt with the form.
Your answer
Date purchased *
Amount to be reimbursed *
enter without pound sign - i.e. £27.50 would be 27.50
Your answer
Bank account number *
Your answer
Bank account sort code *
format with spaces, no dashes e.g. 12 34 56
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms