Travel Reimbursement Form Template - Free Download
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Travel Reimbursement Request Form
Submit to: Front Desk
Department of Pharmaceutial Sciences
Irvine, CA 92697-3958
Account Name or Number to be Charged:
Social Security # (if not UCI Employee):
Date/Time/Location of Departure:
SUMMARY OF EXPENSES (fill in all that apply):
Agency/Car Rental Cost:
License Plate #:
Please fill in amounts expended for each day in appropriate categories outlined below.
Per Diem rates (meals and incidentals) are capped at $46 per day.
(additional space for detail is
available on back if
Total Amount to be Reimbursed:
The above is a true statement of travel expenses incurred by me on official University business on the date(s) shown and I have attached
original receipts for all expenses.
ORIGINAL RECEIPTS ARE REQUIRED AT ALL TIMES
Please tape small receipts to 8 ½ x 11 sheet of paper. Please do not staple.
Information on Individual Receiving Reimbursement:
Date/Time of Return:
Purpose of Trip:
Submit by Email