Traveler Form - U.s. House Of Representatives Committee On Ethics Page 2
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1
2U.S. House of Representatives
Committee on Ethics
TRAVELER FORM
1. Name of Traveler: _________________________________________________________________
2. Sponsor(s) (who will be paying for the trip): _____________________________________________
_________________________________________________________________________________
3. Travel destination(s): _______________________________________________________________
4. a. Date of departure _____________________ Date of return: _____________________________
b. Will you be extending the trip at your personal expense?
Yes
No
If yes, dates at personal expense: __________________________________________________
5. a. Will you be accompanied by a relative at the sponsor’s expense?
Yes
No
b. If yes:
(1) Name of accompanying relative: ________________________________________________
(2) Relationship to traveler:
Spouse
Child
Other (specify): _____________________
(3) Accompanying relative is at least 18 years of age:
Yes
No
6. a. Did the trip sponsor answer “yes” to Question 9(d) on the Primary Trip Sponsor Form (i.e., travel is
sponsored by an entity that employs a registered federal lobbyist or foreign agent and you are
requesting lodging for two nights)?
Yes
No
b. If yes, explain why the second night of lodging is warranted:
______________________________________________________________________________
______________________________________________________________________________
7. Primary Trip Sponsor Form is attached, including agenda, invitee list, and any other attachments and
contributing sponsor forms:
Yes
No
NOTE: The agenda should show the traveler’s individual schedule, including departure and arrival times
and identify the specific events in which the traveler will be participating.
8. Explain why participation in the trip is connected to the traveler’s individual official or representational
duties. Staff should include their job title and how the activities on the itinerary relate to their duties.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
9. Is the traveler aware of any registered federal lobbyists or foreign agents involved in planning,
organizing, requesting, and/or arranging the trip?
Yes
No
10. FOR STAFF TRAVELERS:
TO BE COMPLETED BY YOUR EMPLOYING MEMBER:
A
A
E
T
DVANCED
UTHORIZATION OF
MPLOYEE
RAVEL
I hereby authorize the individual named above, an employee of the U.S. House of Representatives who
works under my direct supervision, to accept expenses for the trip described in this request. I have
determined that the above-described travel is in connection with my employee’s official duties and that
acceptance of these expenses will not create the appearance that the employee is using public office for
private gain.
Date: ____________________
_____________________________________________
Signature of Employing Member
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