Traveler Form - U.s. House Of Representatives Committee On Ethics

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U.S. House of Representatives
Committee on Ethics
This form should be completed by House Members, officers, or employees seeking Committee approval of
privately-sponsored travel or reimbursement for travel under House Rule 25, clause 5. The completed form
should be submitted directly to the Committee by each invited House Member, officer, or employee, together
with the completed and signed trip sponsor form(s) and any attachments. A copy of this form, minus this
initial page, will be made available for public inspection. Form (and any attachments) may be faxed to the
Committee at (202) 225-7392, sent or delivered to the Committee at 1015 Longworth, or e-mailed to
Absent exceptional
circumstances, permission will not be granted for requests received less than 30 days before the trip
commences. You must receive explicit approval from the Committee before you depart on this trip.
Name of Traveler: _____________________________________________________________________
NOTE: Willful or knowing misrepresentations on this form
may be subject to criminal prosecution pursuant to 18 U.S.C. § 1001.
I certify that the information contained on both pages of this form is true, complete, and correct to the
best of my knowledge.
Signature: _______________________________________________________________________
Name of signatory (if other than traveler): ____________________________________________
For staff, name of employing Member or committee: ___________________________________
Office address: ___________________________________________________________________
Telephone number: ________________________________________________________________
Email address of contact person: ______________________________________________________
Check this box if the sponsoring entity is a media outlet, the purpose of the trip is to make a media
appearance sponsored by that entity, and these forms are being submitted to the Committee less than
30 days before the trip departure date.
NOTE: You must complete all of the contact information fields above, as Committee staff may need to
contact you if additional information is required.
KEEP A COPY OF THIS FORM. Page 2 (but not this page) must be submitted to the Clerk as part of the
post-travel disclosure required by House Rule 25. Travel Regulation § 404(d) also requires you to keep a
copy of all request forms and supporting paperwork for three subsequent Congresses from the date of travel.
If there are any questions regarding this form please contact the Committee:
Committee on Ethics
1015 Longworth House Office Building
Washington, DC 20515
(202) 225-7103 (phone)
(202) 225-7392 (fax)
Travel email:
Version date 2/2013 by Committee on Ethics


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