Instructional Travel Form - Monthly Mileage Report
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1Revised 1/11/16
Instructional Travel Form – Monthly Mileage Report (Reg. 484) MONTH __________________ YEAR
Date:
Name:
Banner ID:
Address: City
State
Zip
Dept:
(check one) Full-Time
Part-Time
(check one) Campus Mail
Mail to home
A
B
C
Actual
Deduction:
Daily
RT mileage from
Daily
reimbursable
Description of route
Residence to Home
Mileage
mileage
Date
Purpose
Office
From Origin to
Origin (residence) Destination 1
or
Final
Destination 2… Final Destination (residence)
(A minus B)
50 miles
Destination
for PT faculty
Total Reimbursable Mileage for Month =
.54
0.00
Total mileage
X $______ = $
Budget Number_________________________
Requestor’s signature _______________________________________
Date____________
Supervisor’s signature ______________________________________
Date____________
Vice President/Dean signature ________________________________
Date____________
*effective Fall 2011
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Parent category: Business