S02 - Attachment 11 -Travel Authorization Request.docx

Contractor Travel Authorization Request (Official Contract Number: _____________) (Contract

#: _____________ PO#: _____________ )

Date of Request: _________________________________________ Name (Last, First, Middle): ______________________________________________________ Signature Required: ________________________________ Date Signed: _____________

Rental Car Confirmation #: __N/A_________

Brief detailed purpose for trip:

Brief description of intended accomplishments in order to meet contract requirements /deliverables and or task orders:

Duration of Trip (excluding travel days): _______________

Approximate Costs:

Transportation: _______________________________________________________

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

TOTAL: ___________________

Remarks:

Contractor Signature Required:_______________________ 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 any and all incurred travel expenses. In addition, I shall submit copies of all receipts upon request to the COR. Focus of this meeting is organization and program management. There will be no information shared that will require security clearance, such as patient information.

Government Use Only:

Funding against contract number: ___________________ Authorization:

Approved: Yes _____ No _____ Reason not approved:

**To be scanned into Official Contract File