Travel Request Form

Work email address of the person completing this request *:

Agency Name:

Deadline for Approval

Fiscal Year:

Employee Information

Employee Name:

Employee Id:

Employee Position:

Employee Division/Department:

Name of Conference:

Purpose and Benefit to Agency and the State:

Fiscal Impact

Travel Destination:

Departure Date:

Return Date:

Airfare:

Lodging:

Registration:

Transportation:

Per Diem:

Other/Baggage:

Total Estimated Cost:

State Source:

Federal Source:

Revolving/Fees:

Outside Funding Source:

Total from Sources:

Other funding Source/Sponsorships (please describe):

Is the travel required by the funding source?:

If yes, please list award?:

Are there other avenues of participation other than in person attendance i.e., video conference, web-based sharing of information etc.?:

Travel related to National Board Member/Committee Appointments:

National Board/Committee Name:

Is the travel related to the board/committee?:

If yes, are you an Officer?:

Position Held:

Duration of Appointment:

Does the Board or Committee have meetings scheduled for the remainder or current Fiscal Year?:

If so, please list destination(s) and date(s) below for consideration of blanket approval(s) specific to Board or Committee commitment. (Blanket approvals will only apply to specified Board/Committee meetings listed below.)

From:

To:

Destination:

From:

To:

Destination:

From:

To:

Destination:

From:

To:

Destination:

From:

To:

Destination:

Please list any other relevant information not captured above: