Authorization For Foreign Travel & Request For Insurance Program (Ftip) Coverage Form printable pdf download

the University Corporation, San Francsico State

P.O. Box 320160

San Francisco, CA 94132

Authorization for Foreign Travel & Request for Insurance Program (FTIP) Coverage

Reset

Please complete all items listed below. Attach separate sheets as needed.

1. Travel Information

Destination of travel (city & country):

Departure date from USA:

Return date to USA:

UCorp project account number:

2. Trip Leader:

UIN:

NOTE: should be as appears on passport

L A S T , F I R S T M I

Trip Leader Status: (check one) ___UCorp employee ___SFSU faculty ___SFSU staff ___ SFSU student ___ Other

Campus extension:_____________ Other contact phone number: __________________________

Campus/other email address: _________________________________________________________________________

Emergency contact for Trip Leader & relationship: ________________________________________________________

Phone: ______________________ Cell phone:_____________________ E‐mail:_____________________________

Activity description: __________________________________________________________________________________

Purpose of travel: ____________________________________________________________________________________

UCorp project or SFSU Department sponsoring travel: _____________________________________________________

3. Participant List & Foreign Travel Schedule ‐ complete & submit:

(required only if 2 or more travelers)

[a] Participant List form & provide each traveler's emergency contact

[b] Foreign Travel Schedule form listing traveler's passport name & dates for departure from‐/return to‐ USA

4. Itinerary & Trip Details

Attach to this form: copy of trip itinerary; activity description, & related trip details, so you may be contacted

in event of an emergency. Attacch separate sheets as needed.

‐ List primary/secondary accomodations, including foreign address & foreign telephone number of each location:

‐ List general activities re: trip (i.e., attending conference/mtg, collecting data, field research, teaching, etc.,.)

‐ Provide info on primary mode of transportation at destination (i.e., taxi, car rental, public transportation, etc.,.)

5. Project Director Approval:

NAME ___________________________________ SIGNATIURE ________________________________

6. Signature of College Dean (or VP) Approving Travel: ____________________________________________________

FOR OFFICE USE ONLY

7. Acknowledgement of Office of Risk Mgmt/SFSU: _______________________________________________________

8. Signature of Provost Approving Travel: ________________________________________________________________

SFSU President Approval: _______________________________ CSU Approval: ______________________

Return completed form to: Risk Mgmt/ADM252 (or fax to x82498, with a copy to UCorp/ADM361)

Authorization For Foreign Travel & Request For Insurance Program (Ftip) Coverage Form