Cariant Expense Report & Mileage Log
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1
2
3CARIANT EXPENSE REPORT
(4/13/03)
EMPLOYEE’S NAME
(PRINT)
SUPERVISOR’S NAME
(PRINT)
SOCIAL SECURITY NO.
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|
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__1__
___1_
PAGE
OF
EMPLOYEE’S ADDRESS (TO SEND CHECK)
CITY
STATE AND ZIP
EXPENSE FOR WEEK
01 PT
! 02 OT
!
TAPE RECEIPTS TO 8 ½ x 11 PAPER & STAPLE TO BACK.
DISCIPLINE
!
ENDING (SATURDAY)
FILL OUT MILEAGE LOG ON BACK. SUBTOTAL MILEAGE BY DEPT.
03 SLP
EMPLOYEE: SIGN AND SEND ORIGINAL TO SUPERVISOR
! 10 RN ! 11 LPN ! 12 CNA !
99 OH
PERSONAL AUTO USE: I CERTIFY THAT I HAVE AT LEAST THE MINIMUM STATE REQUIRED AUTO INSURANCE " INITIAL______
(A)
MILEAGE EXPENSE BY FACILITY
DEPT #
NUMBER OF
732 $ AMOUNT
ENTER
(
)
FROM BACK
(4 DIGITS)
MILES
/
(MILES * RATE)
RATE
MILE
TOTAL MILES AND MILEAGE EXPENSE AMOUNT
(A)
(B)
BUSINESS EXPENSE
ACCOUNT
DEPT #
CODE 650,
$
CONTINUING EDUCATION 650
LICENSE/DUES 661
AMOUNT
D
AT
707, ETC.
OFFICE SUPPLIES 707
POSTAGE 709
PHONE 710
REPAIRS 720
E
TOTAL BUSINESS EXPENSE AMOUNT
(B)
$
(C)
TRAVEL EXPENSE
DEPT #
730
D
AT
BUSINESS PURPOSE:
$
AMOUNT
E
AIRFARE
FROM:
TO:
HOTEL
OTHER
TOTAL TRAVEL EXPENSE
(C)
$
(D)
BUSINESS MEAL EXPENSE
DEPT # :
731
OTHERS:
TYPE
D
AT
EMPLOYEES
BUSINESS PURPOSE
PLACE
B, L, D
$
NAME/TITLE/COMPANY
AMOUNT
E
TOTAL BUSINESS MEAL EXPENSE
(D)
$
I certify that I have incurred all of the expenses recorded on this report on behalf of the company and that they are directly related to the conduct of Cariant business.
☺
EMPLOYEE SIGNATURE
DATE
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