Student Clubs & Organizations

Club/ Organization name *

Today's Date *

Total Amount $ *

Original ITEMIZED recipt(s) must be taped to a blank sheet of paper and stapled onto a paper and turned into the office *

Description of items: *

Dates of Travel: *

Destination: *

Total Amount $ *

Are you seeking reimbursement for gasoline costs? Y? N? *

Private Vehicle Use (Must turn in Google Map- Reimbursement rate is. 14 cents per mile) *

Rental Car (Must turn in Original Paid Receipt) *

All travelers must read and Sign *

Consent *

Date *

Total Amount $ *

Choose One Below *

Guest Lecturer Must Read, Sign & Date *

I HEREBY CERTIFY: That a) I received authorization to travel; b) expenses are true and accurate in accordance with Humboldt Travel Policy and procedures; c) I will not seek reimbursement for these same expenditures from any other source; d) food costs do not include alcohol; e) if requesting mileage reimbursement, I have satisfied the State Defensive Driving Training requirement; Accurate Drivers Background Check; and have completed the STD 261 form (if driving private vehicle) prior to travel. E-Signature *

Date *

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Student Clubs & Organizations