Nome Public Schools
T ravel and Per Diem Request
Legal
N ame
o f
I ndividual
T raveling:____________________________________________
( first,
m iddle,
l ast)
Contact
P hone
( cell)
___Male
__Female
:_________________
Date
o f
B irth:_____________________
Purpose
f or
T ravel
:______________________________________________________________________________
( a$ach
n ecessary
i nforma0on,
e .g.,
a genda)
Dates
o f
e vent
D esBnaBon
:__________________________________
:______________________________
Desired
D eparture
D ate
&
T ime
:___________________
R eturn
D ate
&
T ime:_________________________
Funding
S ource(code)
Total
E s.mated
C ost
o f
T rip:
$ ______________
:_________________________________
(to
b e
c ompleted
b y
t raveler)
Airfare PO#
Lodging PO#
Registration PO#
Per Diem PO#
Other PO#
_____________
_______________
_______________
_______________
__________
Airfare:
Lodging:
Vendor
N ame:____________________________
Vendor
N ame:____________________________
Mileage
# :
_ ______________________________
Dates
o f
S tay:_____________________________
Preferred
S eaBng:
_ ________________________
Est.Cost/Night:$___________
# Nights:_________
EsBmated
C ost:$
_ _________________________
ReservaBon#:_____________________________
Other Costs:
ConfirmaBon
C ode:________________________
Vendor
N ame:____________________________
Registration:
Please
s pecify:____________________________
Vendor
N ame:____________________________
________________________________________
EsBmated
C ost:$__________________________
EsBmated
C ost:$__________________________
RegistraBon#:
_ ___________________________
ReservaBon#:
_ ___________________________
To
C alculate
P er
D iem,
F ill
i n
t he
b lanks
w ith
r equired
p rice.
M eals
i ncluded
w ith
c onference
s hould
b e
m arked
w ith
" X"
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Date
Breakfast $15
Lunch $20
Dinner $25
If an airport shuttle is not complimentary, add $20 taxi/shuttle fee
Total Per Diem
$
*Actual
C ost
o f
T rip:
$ _______________
Requested
b y:________________________________________________________________________________
Supervisor/Budget
A dministrator
a pproval:_________________________________________________________
Superintendent
a pproval:_______________________________________________________________________
Business
M anager
a pproval:_____________________________________________________________________