Travel Reimbursement Worksheet
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1
2UNIVERSITY OF VIRGINIA
PHYSICS DEPARTMENT
TRAVEL REIMBURSEMENT WORKSHEET
RETURN WORSHEET TO ROOM 112A
Gwen Dellinger
924-3798
382 McCormick Road
TRAVELER INFORMATION
Name (Last, First M.I.)
Work Phone Number
Home Street Address Line 1
Home Street Address Line 2
Home City, State, Zip
E-mail address
@virgina.edu
TRIP INFORMATION
Departure Date
TIME
Return Date
TIME
Name of Meeting/Conference
Purpose of Trip
Destination/s (City, State/Country)
Receipts required except for M&IE/Per Diem, mileage and tolls under $5.00.
Public Transportation (boarding pass/ticket required)
Car rental (include gasoline costs incurred)
Personal Car Mileage (only enter amount of miles) $0.540/mile
Registration fees
Parking, Tolls
Business phone calls, faxes
Misc. (please explain)
Total
RATE
# OF DAYS
st
*Lodging 1
location
RATE
# OF DAYS
Total
nd
*Lodging 2
location
PTAO Code
TOTAL:
Per Diem = State/International Rates –
Using Full Per Diem, or use
the following rate/day $_________
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Parent category: Business