Form 45116 - Approval For Conference / Training / Travel - State Of Indiana
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1APPROVAL FOR CONFERENCE / TRAINING / TRAVEL
State Form 45116 (R3 / 11-96) / FM 6005
1. Date of request (month, day, year)
Your Social Security number is being
requested in order to track payment
2. Account number
through the Auditor of State's control
system.
Disclosure is voluntary.
3. Name of agency
4. Name of division
5. Employee telephone number
6. Contact person / telephone number
(
)
(
)
7. Name of employee (last, first, middle initial)
Social Security number
8. Position / title
9. Room number
10. Origin of trip
11. Destination of trip
12. Other employee(s) going on same trip
13. Date and time of departure
14. Date and time of return
Is any portion of the trip personal vacation?
15. Date and time meeting starts
16. Date and time meeting ends
Yes
No
If Yes, give dates
17. Name of conference or seminar
18. Sponsor (name of vendor)
19. Site / location
20. City
State
ZIP code
21. Purpose of travel (Attach on a separate sheet of paper the justification for travel. The following must be included in the first paragraph.)
1. Why it is in the interest of the State that the travel be approved.
2. Name, location and sponsor of conference.
3. Summary on what subjects are to be discussed and explain how this information relates to the specific job functions of traveler.
You must attach a copy of the program or schedule including documentation of dates, location, registration and lodging.
AIRLINE INFORMATION
Departure
Return
Ward Information
22. Airline carrier
27. Airline carrier
32. Name of ward
23. Flight number
28. Flight number
33. Court order attached
Yes
No
24. Departure date
29. Departure date
If No, reason and Fax date
25. Departure time
26. Arrival time
30. Departure time
31. Arrival time
34. Facility contact person and ticket information
35. Specific information on ticket delivery
AMOUNT
EXPENSES
36. Registration fee(s)
Date registration form sent
Date less than $100 registration
Claim voucher sent
$
fee paid
$
Yes
No
37. Transportation (if air travel, be specific
$
Air
Bus
Train
State Car
about ground transportation)
$
Automobile (personal)
$
Automobile (rental)
If none, explain:
38. Lodging per night
No. of days
Tax rate
Name and address of hotel
Confirmation number/letter
$
$
39. Daily subsistence (per diem)
List meals provided
$
40. Other (parking, taxi, shuttle)
Explain
$
If no expense to the State, method of payment/reimbursement
TOTAL
$
APPROVAL INFORMATION (all signatures required)
NOTES
41. Signature of supervisor
Date signed (month, day, year)
42. Signature of Division Director
Date signed (month, day, year)
43. Signature of Budget Director
Date signed (month, day, year)
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