Free 45116.PDF - Indiana

APPROVAL FOR CONFERENCE / TRAINING / TRAVEL
State Form 45116 (R3 / 11-96) / FM 6005 Your Social Security number is being requested in order to track payment through the Auditor of State's control system. Disclosure is voluntary. 3. Name of agency 4. Name of division 5. Employee telephone number 1. Date of request (month, day, year) 2. Account number

6. Contact person / telephone number

(
7. Name of employee (last, first, middle initial) Social Security number

)

(

)

8. Position / title

9. Room number

10. Origin of trip

11. Destination of trip

12. Other employee(s) going on same trip

13. Date and time of departure

14. Date and time of return Is any portion of the trip personal vacation?

15. Date and time meeting starts

16. Date and time meeting ends

Yes

No

If Yes, give dates

17. Name of conference or seminar

18. Sponsor (name of vendor)

19. Site / location

20. City

State

ZIP code

21. Purpose of travel (Attach on a separate sheet of paper the justification for travel. The following must be included in the first paragraph.)

1. Why it is in the interest of the State that the travel be approved. 2. Name, location and sponsor of conference. 3. Summary on what subjects are to be discussed and explain how this information relates to the specific job functions of traveler. You must attach a copy of the program or schedule including documentation of dates, location, registration and lodging. Departure
22. Airline carrier

AIRLINE INFORMATION Return
27. Airline carrier 32. Name of ward

Ward Information

23. Flight number

28. Flight number

33. Court order attached

Yes
24. Departure date 29. Departure date If No, reason and Fax date

No

25. Departure time

26. Arrival time

30. Departure time

31. Arrival time

34. Facility contact person and ticket information

35. Specific information on ticket delivery

EXPENSES
36. Registration fee(s) Date registration form sent

AMOUNT
Claim voucher sent

$
37. Transportation (if air travel, be specific about ground transportation)

Date less than $100 registration fee paid

Yes

No

$ $ $ $

Air Bus Train State Car Automobile (personal) Automobile (rental) If none, explain:
Name and address of hotel Confirmation number/letter

38. Lodging per night No. of days

Tax rate

$
39. Daily subsistence (per diem) List meals provided

$ $

40. Other (parking, taxi, shuttle)

Explain

$
If no expense to the State, method of payment/reimbursement TOTAL

$
APPROVAL INFORMATION (all signatures required)
41. Signature of supervisor Date signed (month, day, year)

NOTES

42. Signature of Division Director

Date signed (month, day, year)

43. Signature of Budget Director

Date signed (month, day, year)