Employee Mileage and Conference Form

EMPLOYEE MILEAGE AND CONFERENCE FORM

Use this form to request reimbursement for mileage and approved conference-related expenses. Complete all sections and attach original receipts where required. Expense amounts are subject to organizational travel and expense policy and may require additional departmental approvals.

Personal Information

Position Information

Employment Start Date:

Conference / Event Details

Event Dates: From To

Mileage Log (Provide each trip separately)

Mileage must be recorded using odometer readings and mileage rate in effect at the time of travel. Enter each trip below. Attach additional pages if necessary.

Travel & Conference Expenses

Provide totals for other reimbursable expense categories and attach itemized receipts.

Reimbursement Calculation

Receipts and Attachments

Check all attachments included with this submission. Original receipts are required for amounts above organizational per-item thresholds. Failure to provide receipts may delay reimbursement.

Administrative / Chartfield

Supervisor Approval (check if approved): Approved Date Approved:

Legal Disclosures & Authorization

At-Will Employment: Employment relationships are at-will unless a written agreement states otherwise. Nothing in this form changes the at-will nature of employment or creates contractual rights.

Equal Opportunity: The organization is an equal opportunity employer. Reimbursement decisions are made without regard to protected characteristics and in accordance with applicable policies.

Authorization and Certification: I certify that the expenses claimed on this form were incurred while conducting official business for the organization, are true and correct, and comply with organizational travel and expense policies. I authorize the organization to contact prior employers and third parties as necessary to verify representations made in this form or related personnel records in accordance with applicable law.

Employment History (required)

Provide at least two prior employers. This information may be used for verification in accordance with personnel policies.

Dates Employed: to

Dates Employed: to

Education

Graduation Date:

References (Professional)

Provide three professional references who can verify work performance and conduct.

Applicant Certification

I certify under penalty of perjury that the information provided on this form is true, accurate, and complete to the best of my knowledge; that expenses claimed were incurred in the course of performing my assigned duties; and that I will promptly reimburse the organization for any amounts determined to be ineligible. I understand that falsification of information may result in disciplinary action up to and including termination and recovery of funds.

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