aapc travel confirmation form by JdaU3Rk4

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									                                  TRAVEL CONFIRMATION FORM
PLEASE COMPLETE THIS CONFIRMATION FORM AND EMAIL TO: MII@usdoj.gov 30 days
before you plan to travel to your test site location.

COURSE NAME: CPT CODING – AAPC TESTING
PROJECT CODE: CMS1    ACCOUNTING CODE: 0E407207
Name:

Social Security # (needed for travel expenses reimbursement process)

Title:

Agency/Department:

Office Address:

Office Telephone:


Office Fax:


Email Address:

Emergency Contact:
(Name and Phone Number)

DCN # (please leave blank - to be completed by MII staff)
Testing Date and Location:
(City and State)
                                                                              Roundtrip
                                                                                                Is this a one day
                                                                            mileage total
                                                                                                        trip
                                                                           from home to
Travel                                                                                                  Y/N
                                                                             Testing Site


* If your travel requires an overnight stay/lodging, you will
need to contact the MII for additional information before
reserving a room.
(803) 705-5145/5077
MII@usdoj.gov

** Travel Authorization/Confirmation Form & Travel Voucher: Your Social Security Account Number (SSN) is solicited
under the authority of the Internal Revenue Code (26 U.S.C. 6011(b) and 6109) and E.O. 9397, November 22, 1943, for
use as a taxpayer and/or employee identification number; disclosure is MANDATORY on vouchers claiming travel
payment or reimbursement which is, or may be taxable income. Failure to furnish the information requested may result
in total or partial denial of the amount claimed.

								
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