TRAVELER'S REQUEST FOR PREMIUM-CLASS TRAVEL
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the purpose of the form and how it will be used. Please read it carefully. AUTHORITY: 5 U.S.C. 5701 - 5733, particularly 5721 - 5733; 30 U.S.C. 905 and E.O. 9397 (SSN). PRINCIPAL PURPOSE(S): Information provided on this form will assist the approval authority with determining whether or not the use of other than coach-class accommodations needs to be provided for the traveler. The data obtained on this form will provide management information for control of travel expenditures. ROUTINE USE(S): Information may be released to appropriate Federal, State, local or foreign agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply. DISCLOSURE: Voluntary; however, if the requested information is not provided, the approval authority may disapprove the traveler's request. Individual requests must be submitted through the organization's OSD Component Head to the Director, Administration and Management. Component Heads may fax (703-601-3000) or e-mail ([email protected]) the request for processing.
1. TRAVELER'S NAME (Last, First, Middle Initial) 4. TRAVELER'S ORGANIZATION 5. TRAVELER'S WORK TELEPHONE NUMBERS (Include area code) a. COMMERCIAL b. DSN 6. TRAVELER'S E-MAIL ADDRESS 2. TRAVELER'S RANK 3. TRAVELER'S SSN
7. PERSON PREPARING TRAVEL ORDERS a. NAME (Last, First, Middle Initial) 8. MODE OF TRAVEL (X as applicable) AIR SHIP TRAIN
b. TELEPHONE (Include Area Code)
9. TRAVEL PURPOSE (X as applicable. Definitions for each category may be found in the JTR/JFTR.) SITE VISIT INFORMATION MEETING TRAINING SPEECH/PRESENTATION a. ORIGIN CONFERENCE RELOCATION ENTITLEMENT TRAVEL SPECIAL MISSION TRAVEL b. DESTINATION EMERGENCY TRAVEL OTHER
10. LOCATION WHERE PREMIUM-CLASS TRAVEL SEGMENTS START AND END (Enter all segments.) (1) (2) (3) (4) 11. DATE TRAVEL TO BEGIN (YYYYMMDD) 12. FARE FOR PREMIUM TRAVEL 13. FARE FOR COACH CLASS
14. TICKET ISSUING LOCATION (Name and Location of Commercial Travel Office (CTO))
15. REASON FOR REQUESTING PREMIUM-CLASS TRAVEL (Cite specific paragraph of the JTR/JFTR)
16. DESCRIBE WHY PREMIUM-CLASS TRAVEL IS ESSENTIAL TO YOUR TRAVEL (If due to a disability or other special need, you must complete Section II on the second page of this form and request your physician to complete the Medical Physician's Statement for Premium-Class Travel.)
17. CERTIFICATION AND CONSENT BY TRAVELER I hereby certify that all statements made hereon are true to the best of my knowledge and belief. I hereby give my permission for the release of information about my service and conditions (i.e. disease and injury) to authorized agency officials and medical consultants.
a. SIGNATURE OF TRAVELER b. DATE OF REQUEST (YYYYMMDD)
SD FORM 817 TEST, MAR 2005
TRAVELER'S NAME (Last, First, Middle Initial)
SECTION II - REQUEST DUE TO DISABILITY OR OTHER SPECIAL NEED
18. DESCRIBE YOUR DISABILITY OR SPECIAL NEED AND HOW IT INTERFERES WITH TRAVELING IN COACH CLASS
19. GIVE THE APPROXIMATE DATE (Month/Year) YOUR CONDITION BEGAN TO AFFECT YOUR ABILITY TO TRAVEL WITHOUT SPECIAL TRAVEL ACCOMMODATIONS 20. WHAT IS THE EXPECTED DURATION OF YOUR CONDITION?
21. WHAT ACCOMMODATION (e.g., bulkhead seating, two coach seats, seat cushion, aisle seat, etc.) COULD BE USED SO THAT YOU WOULD BE ABLE TO TRAVEL IN COACH CLASS?
SD FORM 817 TEST (BACK), MAR 2005