Out Of State Travel Request And Authorization

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OUT OF STATE TRAVEL REQUEST AND AUTHORIZATION
All Out of State and Out of Country travel authorization forms must be
Out of State
Out of Country
submitted to the Governor’s Office for review.
TRAVELER INFORMATION:
NAME:
TITLE:
PHONE:
EMAIL ADDRESS:
FUNDING SOURCE: General
Cash Fund
______%
______%
Cash Funds Exempt
%
Federal
%
Personal/Employee
%
______
______
______
ORG:
APPR:
PROGRAM:
FUNCTION:
OBJ:
SUB-OBJ:
GBL:
RPTG:
FUND:
AGENCY:
ORIGINATION
DESTINATION
DEPARTURE
RETURN
/
/
/
/
DATE
TIME
DATE
TIME
ESTIMATED EXPENDITURES
MAXIMUM AUTHORIZED EXPENDITURE
TRANSPORTATION – AIR
$
TRANSPORTATION – AIR
$
TRANSPORTATION – OTHER
$
TRANSPORTATION – OTHER
$
LODGING
$
LODGING
$
MEALS
$
MEALS
$
REGISTRATION FEE IF ANY
$
REGISTRATION FEE IF ANY
$
INCIDENTAL EXPENSES
$
INCIDENTAL EXPENSES$
$
TOTAL
$
$
0
0
TOTAL MAXIMUM AUTHORIZATION
For Which Reimbursement
$
Can Be Obtained
METHODS OF PAYMENT:
State ONE Card
State Central Travel Card
State IB Travel Card
Central Travel Account for Airfare
AIRLINE
RENTAL CAR AGENCY
(VENDOR NAME)
(VENDOR NAME)
AVIS
BUDGET
ENTERPRISE
NATIONAL
HERTZ
N/A
OTHER
_____________________
PURPOSE AND JUSTIFICATION OF TRAVEL
NON-CONFERENCE RELATED
CONFERENCE RELATED – NAME OF CONFERENCE
__________________________________________________________
IDENTIFY PERSONS AND/OR ORGANIZATIONS TO BE CONTACTED: If travel is for Washington D.C., the form must specify contacts with
any member of Congress, his or her Staff, or Federal Government Department or Agency Personnel.
NAMES
TITLE
ORGANIZATION
TOPIC
SIGNATURE OF TRAVELER
DATE
/
/
APPROVED
SIGNATURE OF APPOINTING AUTHORITY
DATE
DISAPPROVED
/
/
APPROVED
SIGNATURE OF EXECUTIVE DIRECTOR (OR DELEGATE)
DATE
DISAPPROVED
/
/
DPA/STMP/June 28, 2013
RESET

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