1. Name of Traveler:
First: Last:

2. Date:
3. Traveler's Position and Department of Office:

4. Purpose of Travel and Destination:

5. Dates of Absence from the University:

6. Address or Phone: (in case of emergency)
7. Classes to be missed by the traveler:
Course Number:
Course Name:
Hours:
Dates:

8. Provisions made for handling the classes to be missed:

9. Travel Expenses to be paid by: University Other:

10: For University Allowed Expenses:

Account Number and Name:
Estimated Cost:

11. Remarks by the Traveler:
Type Name:  
Traveler:
Principal Investigator
Chairman
Dean