Delta State University
Travel Authorization and Reimbursement Form
Fill in Sections A, B, C and D only for Travel Authorization. Upon return, fill in back of form for reimbursement.
First Middle Initial Last Employee Number
Department: Campus Address: Dept. Phone:
Date of Travel From: To:
Mode of Transportation:
Accompanied by: Amount of Airline Ticket:
Itinerary From: To:
Purpose of Trip:
Department to be Charged Fund Organization Account Activity # Amount
Section C - Advance (for out-of-state or group/team travel only)
An advance payment is requested for this travel. Date Advance is Needed:
(Check box if applicable)
If this request is approved, I agree to send to the President a statement indicative of the service rendered to the University through the travel authorized.
It is expressly understood and agreed that the amount advanced will be deducted from my total approved out-of-pocket expenses.
If the amount advanced exceeds the amount of such expenses, it is further understood that my personal check made payable to
'DSU' will accompany the reimbursement form. If the advance remains unsettled after 10 working days after the end of the month
in which travel was completed, it will be withheld from my next paycheck, as authorized by my signature below.
Requested by: Date Submitted:
Verified by: Approved:
Department Chair or Next Higher Administrator Director of Procurement
Travel Authorization form must be received at least 3 business days prior to trip or, if an advance is
requested, 7 business days prior to the trip.
Request for Reimbursement must be made within the first week after return from the authorized trip.
Request for permission to travel outside the continental limits of the United States must be submitted
and approved in advance of actual traveling date(s) by the President's Office.
Statement of cost of meals and lodging
Mo/Day/Year Breakfast Lunch Dinner Hotel Room Daily Total Place Where Expenses Occurred
Total of Daily Total to Section F-1 (attach continuation page if needed) $ -
Other Authorized Expenses (*Receipts must be attached to Reimbursement)
*Gas for University Vehicle *Business Phone Calls *On Site Registration *Rental Vehicle
*Other University Vehicle
*Parking *Table or Booth Fees *Gas for Rental Car
Other (Please Specify) Other (Please Specify) Other (Please Specify) Other (Please Specify)
Total of Section F-3 $ - Total of Section F-4 $ - Total of Section F-5 $ - Total of Section F-6 $ -
Receipts must be presented at time of Reimbursement
Air Fare Miles Traveled 0 X 0.5 0.00
Train Gas (if not getting reimbursed for mileage)
Bus Total of Section F-2 $ -
Total of Section F-7 $ -
For Amount For Amount
1. Meals and Lodging 5. Registration Fees
2. Travel by Private Vehicle 6. Travel by Rental Vehicle
3. Travel by University Vehicle 7. Travel by Public Carrier
4. Other Travel Costs
Total Voucher $ -
Less Advance $ -
Reimburse to traveler* $ -
*If amount of the advance exceeds Total Voucher above, attach a personal check payable to 'DSU' to this form.
Subject to any differences determined by verification, I certify that the above amount claimed by me for travel expenses for the
period indicated is true and just in all respects, and payment for any part thereof has not been received. Penalty for Presenting
Fraudulent Claim - Fine of not more than $250; civilly liable for full amount received illegally, and in addition removal from the office
or position held by the person presenting the claim (Section 25-3-45, Mississippi Code of 1972)
Approved for Payment: Date:
Department Chair or Next Higher Administrator