Clerkship Travel Program (Reimbursement Form) To process this request, all information denoted by an asterisk below must be filled in. Contact Information Queen's Email Address Queen's emails ONLY, not your Qmed email. Example: mynetid@queensu.ca Student Number Student First Name Student Last Name Grad Year Elective Information Elective Name Elective University Elective Hospital/Clinic Preceptor(s) Name(s) Start Date of Elective End Date of Elective Other Comments Leave this field blank
