Travel Budget Form - Ophthalmology

Have you received approval to travel from your Program Director?*

Yes
No

STOP: You must have approval for travel from your supervisor.

You will still be able to submit this form, but it will not be approved without documentation of approval for travel from your supervisor.

Please attach approval letter*

Accepted file types: pdf, doc, docx, jpg, gif, png, Max. file size: 100 MB.

Name*

First Last

Email*

Departure Date*

This date will be the day you leave to go to the meeting/conference.

Return Date*

This date will be the day you return from the meeting/conference.

Name of Meeting/Conference*

Enter the name of the meeting/conference you will be attending

Destination (City/State)*

Enter the name of the city and state the meeting/conference will be in.

Transportation Method*

How will you be traveling?

Plane
Bus
Train
Personal Vehicle

Transportation Expenses

Estimate cost of transportation. Research is encouraged to get as close an estimate as possible. If you will be traveling by personal vehicle, please enter 0.00 and enter estimated mileage below.

Justification and Expense for Car Rental

Write the justification for the need of a car rental at your destination.

Lodging Expenses

Anticipated cost of lodging during stay at destination of meeting/conference. Research is encouraged to get as close as estimate as possible.

Registration Fees

Total cost of registration fees for the meeting/conference even if they were already paid.

Parking/Toll Expenses

Anticipated cost of parking fees at airport, hotel, or conference as well as any toll fees that may occur during trip.

Will you have any other expenses or fees to report?*

Yes
No

Miscellaneous expenses

Please describe anticipated expenses/fees and put full amount by each description.

Please sign to indicate that you have read and filled out everything to the best of your knowledge and understand what is required for full reimbursement.*

You must bring all meal receipts - itemized - and submit to Liz Blough. You can also choose to snap a picture and email to Liz at the end of your trip. Please submit only ONE email for ALL itemized Meal Receipts. If you choose to take a picture, it MUST be legible with the NAME of the establishment, DATE & TIME showing clearly.