Employee Traveler Certification

EMPLOYEE TRAVELER CERTIFICATION

This Employee Traveler Certification documents the employee's acknowledgement of travel authorization, compliance with employer travel policies, duties and certifications required for business travel. Completion and signature certify that the employee has read, understands, and will comply with all applicable policies and acknowledges the authorizations in this form.

Personal Information

Position Information

Travel Details

Departure Date:

Return Date:

I confirm pre-approval has been granted by the authorized approver

Travel Mode: Air Car/Rental Train Other

Will you operate a motor vehicle for business purposes during this travel?

Will the travel include overnight lodging?

Employment History

Employer 1

Dates Employed: From To

Employer 2

Dates Employed: From To

Education

References

Reference 1

Reference 2

Reference 3

Legal Disclosures & Acknowledgements

At-Will Employment: Employee acknowledges that employment status and terms remain at-will unless a separate written agreement expressly states otherwise and is signed by an authorized representative.

Equal Opportunity: The employer provides equal employment opportunity and does not discriminate on the basis of legally protected characteristics. Employee understands that all travel, assignments, and reimbursements will be administered consistent with applicable nondiscrimination obligations.

Safety and Conduct: Employee certifies that they will comply with all applicable laws, company travel and expense policies, and safety protocols while traveling. Employee will not operate a vehicle while impaired and will report any incident, accident or injury to their manager and the designated company safety contact immediately.

Expense Accuracy: Employee agrees that all expense reports submitted for reimbursement will be accurate, supported by required receipts, and that false claims may result in disciplinary action up to and including termination and restitution.

Insurance and Indemnification: Employee acknowledges any personal automobile insurance responsibilities when operating a private vehicle on company business. Employee agrees to cooperate with insurer and company investigations and to indemnify the company for damages arising from willful misconduct or breach of policy.

Authorization & Background Verification

Authorization to Contact Employers: I authorize the employer to contact prior employers and references I have identified for the purposes of verifying my employment history, job performance, and suitability for travel-related responsibilities.

Consent to Background Check: I consent to any background or driving record checks that may be required as a condition of authorization to travel or to operate a vehicle on company business. I understand that the continued authorization to travel may be contingent on satisfactory results of such checks in accordance with company policy and applicable law.

Disclosure of Medical Conditions: To the extent required by company policy and applicable law, I will disclose any medical condition that might materially affect my ability to perform duties or safely travel. I understand medical information will be handled in accordance with applicable privacy protections.

Applicant Certification

I certify that all information provided on this form and any attachments is true, accurate and complete to the best of my knowledge. I understand that omission or misrepresentation of material facts may result in disciplinary action, including denial of travel authorization or termination of employment.

By signing below I acknowledge that I have read and understand the travel policies and legal disclosures above, authorize the company to conduct the verifications described, and agree to comply with company travel and expense rules.

I certify the foregoing and authorize the described contacts and checks

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