Non-State Employee Travel Reimbursement Form

Name: Agency: Mailing Address: Beginning Odometer/License:City: State: Zip: Ending Odometer/License:Destination/Purpose of Travel:

Depart From: Departure Time: Return To: Return Time:

Travel Dates:Sat Sun Mon Tues Wed Thu Fri

TOTALGround Transportation:Meals:Lodging:Airfare:Other (explain):TOTALRemarks: Subtotal

Subtotal Addl. PagesTOTAL

Traveler’s Signature Date

Approved for reimbursement by:

_____________________________________________________________ ________________________________Governor’s Office of Highway Safety Director DateAlberto Gutier

Funding Source:

The traveler is not entitled to a meal allowance for substantial meals provided free at a state institution, on an airplane, included in conference registration fees or provided on a complimentary basis by the hotel. A substantial meal is one that includes a serving of protein, i.e. meat, poultry, fish, seafood or eggs.