COMMllTEE ON RESEARCH, ACADEMIC SENATE, LOS ANGELES DIVISION

							                                                          Department of Physiology
                                                   TRAVEL REIMBURSEMENT REQUEST FORM

Name of Traveler                                                    E-mail Address                    Date


Employee ID No.                     Department/Division             Address                           Phone No./Extension



 REQUEST IS MADE FOR TRAVEL EXPENSES
 FROM                                                             TO                                                   AND RETURN
                  POINT OF DEPARTURE DESTINATION
                             THE FOLLOWING INFORMATION IS SUBMITTED IN SUPPORT OF THIS APPLICATION
TITLE AND PURPOSE OF CONFERENCE OR MEETING:


NAME OF ORGANIZATION SPONSORING THE ABOVE-LISTED CONFERENCE OR MEETING:


DATE (S) OF MEETING                   PLACE OF MEETING                                                Reimbursement Requested:
                                                                                                          $
 PLEASE ATTACH THE FOLLOWING TO THIS REQUEST FORM:
 A.   All ORIGINAL itemized receipts. (Please tape the ORIGINAL itemized receipts on an 8 ½ x 11 sheet of paper
       along with proof of payment.)
                                                                                                      Amt (US$)       Foreign Currency

      1. Airplane Fare: Original ticket, or Website Receipt/Itinerary, or Electronic Ticket
         (showing credit card confirmation). Travel tickets purchased through UCLA
         Travel Office will be paid by a P.O.# issued through our purchasing office.
      2. Registration: Receipts and a copy of the registration form are required for all
         registration fee reimbursements, regardless of the amount.
      3. Meals will be reimbursed based on the actual amount spent, up to a daily
         maximum of $64.
      4. Transportation (Shuttle, Taxi, Car): If private car is used, please provide us
         with (a) License Plate Number, (b) A statement confirming that you have
         Liability Insurance.
      5. Hotel: Original itemized hotel bill.

 B. ONE Proof of Payment per receipt

           Credit Card Payments: A copy of bank of credit card statement showing the same dollar amount
           indicated on your invoice/receipt.
           Checks: Front and back copy of a cleared check. A copy of your bank statement from the website is also
           acceptable.
           Cash: Itemized receipt indicating CASH payment.
REMARKS:
                                                                   SIGNATURE of TRAVELLER:

                                                                                     Prepared By:

                                                                                        PI NAME:

                                                                                 PI SIGNATURE:

                                       DO NOT FILL IN BELOW THIS LINE – FOR BUSINESS OFFICE ONLY
 THE ABOVE REQUEST FOR TRAVEL HAS BEEN APPROVED FOR THE AMOUNT OF $


 APPROVED BY:
                        FUND MANAGER                                                               DATE

LINE       LOC        ACCOUNT          CC          FUND   PROJECT      SUB      OBJECT      SOURCE         AMOUNT            INITIALS
  1         4
  2         4

                                                                                                                    Revised on 01/14/07