Attachment 13 Sample Travel Authorization Request Form.docx
DOCX document 22 KB Posted
- Attached to
- Recovery Coordination Program Federal contract opportunity
- Solicitation number
- HT0011-20-R-0023
- Issued by
- Defense Health Agency
About this file
This document contains a sample travel authorization request form for a federal contractor. The form requires information such as employee name, origin, destination, purpose of travel, travel dates, estimated expenses including airfare, lodging, per diem, rental car, personal vehicle mileage, and other expenses. Estimated total costs are provided, and the traveler and government contracting officer representative signatures are required.
The related federal contract opportunity is a non-personal services contract issued by the Defense Health Agency to provide professional, administrative, and management support for the Recovery Coordination Program, including support for transition of care systems, caregiver support, education and employment initiatives, operation warfighter internships, the national resource directory, and warrior games coaching support.
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Text version
Attachment 13 Sample Travel Authorization Request Form
TRAVEL AUTHORIZATION REQUEST
Contract #:
Date of Request:
Employee Name:
Origin:
Destination:
Purpose of Travel:
Begin Travel (Date & Time):
End Travel (Date & Time):
Estimated Expenses:
Air Fare
| $ per day |
| X |
| # of Days |
Lodging
| $ |
| X |
| = | |
| $ | 1,557.00 |
Misc & Incidental Expenses (Per Diem
1st Day @ 75%
X
$ 53.25
| Days Between 1st and Last |
| $ |
| X |
| = | |
| $ | 568.00 |
| $ |
| X |
| = | |
| $ | 53.25 |
Auto Rental
| $ | - |
| X |
| = | |
| $ | - |
| Miles | |
| X | |
| $ | 0.580 |
POV (Personal Owned Vehicle)
$ 0.580
$ 464.00
Other Expenses (Conference Fee, Etc.)
Describe
| Units |
| Item |
| X |
| Rate |
| Baggage |
| Bags |
| 0 |
| X |
| $ |
| Uber | |
| Days | |
| 0 | |
| X | |
| $ | - |
| Airport Parking | |
| Days | |
| 0 | |
| X | |
| $ | - |
| Extra Bag Charge | |
| Bags | |
| 0 | |
| X | |
| $ | - |
X
X
X
Total Estimated Cost
$ 2,695.50
Receipts are required for air travel, auto rental, hotel and other non-subsidence items. Receipts must be turned into support a claim for reimbursement within 5 working days of completion of travel.
Traveler Signature
Government COR Signature/Date
File details come from the government source that posted it. Updated .