REQUEST FOR REIMBURSEMENT OF CONFERENCE/PROFESSIONAL ACTIVITY EXPENSES

Employee:  ______________________                    Department:  ___________________________     

Name of Conference or Activity:   _____________________

Location:    __________________________                              Dates:   ___________________   

Transportation Attach invoice for common carrier. OR Attach Mileage Documentation.	ITEMIZATION OF EXPENSES Common Carrier/Company Owned Vehicle From:       To:           ☐			Date(s)	Amount
					$
	Private Vehicle From:   10/12   To:    10/15       Mileage (roundtrip)  _____ x 0.625 ☐				$
Meals  Maximum reimbursement rate for meals and lodging is the state rate as determined by the US General Services Administration. Attach Per Diem Calculation Tool.	Lodging  - Attach Hotel Invoice				$
	Breakfast	Lunch	Dinner
	☐	☐	☐		$
	☐	☐	☐		$
	☐	☐	☐		$
	☐	☐	☐		$
Incidental Expenses  Parking Costs, Highway Tolls, Registration Fees Attach Receipts	Registration Fee-				$
	Parking				$
					$
	TOTAL EXPENSES
Receipts must be attached for each reimbursement request.

I hereby certify that the above is just, due and payable.

Employee ______________    Date: __________________

Executive Director ________________________    Date: _________________________