ATTACHMENT K - Travel Request Form.doc

Contractor Travel Authorization Request

Contract Number: __________________ Task Order #: ______________________

PO#: _____________

Date of Request: _________________ Traveler Name (Last, First, Middle): ______________________________________________________ Position Title:

Security Clearance:

Adjudicated _________ None_______ Awaiting Approval__________ Customer:

Department of Veterans Affairs Organization:

Phone No.:

________________________________ Phone Extension: _____________ Travel Dates:

Start: ________________________ Ending: ________________________ Traveling From:

Airport Code: ____________ Traveling To:

Airport Code: ____________ Airplane Ticket #:

_N/A________________ Hotel Confirmation #: ___N/A___________ Rental Car Confirmation #: __N/A_________ Purpose of trip:

List specific deliverables and/or contract requirements to be achieved:

Duration of Trip (excluding travel days): _______________ Approximate Costs:

Transportation: _______________________________________________________ Lodging:

Per Diem:

Car Rental: (Compact vehicle) _________________________________________________ Other: (Taxi, Metro, Bus, Train, Fees, etc.) __________________________________

TOTAL:

Remarks:

Contractor Signature: ______________________ Date Signed: _______________ I certify under penalty of perjury that this travel is in support of the contract terms/conditions listed in my contract and I am not billing the U.S. Government for personal travel or other expenses not related to the scope of the above contract requirements. I agree to comply with any recordkeeping, reporting, and request as required by The Department of Veterans Affairs and understand that failure to do so may result in non-reimbursements of incurred travel expenses. In addition, I shall submit copies of all receipts upon request to the COR and Contracting Officer.

Government Use Only:

Funding against contract number: ___________________ Authorization:

Program Manager:

COR:

Approved: Yes _____ No _____

If no, reason not approved:

Document to be saved in official COR file.