[Instruction: Insert Company logo/name here.]
Travel Request/Reimbursement Form
Two copies of the completed, signed form must be returned to _______. [Instruction: Insert
return instructions.] Attach all receipts and supporting documents. Please note, failure to
provide all applicable receipts or supporting documents may result in a delay in repayment or
denial of payment of eligible reimbursement. Employee should retain a copy of the completed
form and attachments.
Employee Name: _____ Travel Date(s) ______
Department: _____ Approving Supervisor’s Name: _____
[Comment: This table may be expanded to include additional Company required
information or additional rows.]
Date Expense Explanation Amount Total
I hereby certify that the charges set forth above are true, complete and correct. I hereby certify I
have sought and obtained any and all necessary pre-approvals for the submitted expenses. I
hereby certify all such charges, to the extent submitted, are business-related expenses and
further, that I have not sought and will not seek reimbursement for the same expenses listed
herein from any other source for such expenses, to the extent I am reimbursed by Company.
_______________________________________
Employee Signature
I certify these charges are true and correct to the best of my knowledge, and that I all necessary
pre-approvals were obtained by employee. I hereby approve the above charges.
_______________________________________
Approving Supervisor Signature
© Copyright 2012 Docstoc Inc.