Travel Reimbursement Form Template - Free Download
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Travel Reimbursement Form Template
Travel Reimbursement Form Template
Travel Reimbursement Request Form
Submit to: Front Desk
Department of Pharmaceutial Sciences
147 BSA,
Irvine, CA 92697-3958
Traveler's Name:
Account Name or Number to be Charged:
Social Security # (if not UCI Employee):
US Citizen:
Date/Time/Location of Departure:
SUMMARY OF EXPENSES (fill in all that apply):
Airline/Airfare Cost:
Personal Millage:
Agency/Car Rental Cost:
License Plate #:
Orgranization/Registration Fees:
Liability Insurance:
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.
Date
City
Hotel
Phone
Mileage
$.505/mile
Taxi/
Shuttle
Parking
TOTAL
Explanation/Remarks:
(additional space for detail is
available on back if
necessary)
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.
Traveler's Signature:
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:
Yes
No
Yes
No
Date/Time of Return:
Purpose of Trip:
Mailing Address:
Meals
Submit by Email
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