Florida Department of Health
Florida Department of Health
Sexual Violence Prevention Program
TRAVEL ITINERARY FORM
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***SEND ALL ORIGINAL RECEIPTS ***
GENERAL INFORMATION
Name:____________________________________________ Social Security No. ____________________________________
Purpose of travel:_______________________________________________________________________________________
Mailing address:________________________________________________________________________________________
City:______________________________________________ State:__________ Zip:_________________________________
Home Phone:_______________________________________ Work Phone:_________________________________________
TRAVEL DATES & TIME
Origination: ______________________________________ Destination: ___________________________________________
(Travel From) (Travel To)
Departure Date:___________________________________ Hour of Departure: _____________________________________
Return Date: ______________________________________ Hour of Return: _______________________________________
LODGING INFORMATION
Hotel Name:________________________________________________ Number of Nights in hotel: ____________________
Total tax and room charge: $___________________________________ (attach original receipt)
TRANSPORTATION
City of Origin: ___________________________________City of Destination: ___________________________________
(Airfare: Cost $_________________________________________________________ (attach original ticket and itinerary)
Total Miles driven to & from airport: __________________________________
Taxi / shuttle cost $ _______________________________________________ (attach original receipt)
(Driving Personal Vehicle. Mileage used in computing reimbursement amount shall be based on Official Road Map miles
published by State Department of Transportation.
( Rental Car (AVIS) Cost $___________________________________________ (attach original receipt and itemized bill)
MISCELLANEOUS
Parking / toll costs $ _________________________________________________ (attach receipts)
Travel cannot be reimbursed unless all original tickets and other travel related receipts and forms are turned in to this office within 10 days after traveling: Florida Department of Health, Sexual Violence Prevention Program, Mail: 4052 Bald Cypress Way, Bin A-13 or Courier Mail (Fed Ex etc): 4025 Esplanade Way, Tallahassee, Florida 32399-1723. All expenses will be reimbursed per State of Florida Travel Reimbursement Guidelines.
Signature: _______________________________________________________ Date: _______________________________
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