Mileage Reimbursement Request Form

Mileage references and club address sheet: Mileage Reference Sheet & Club Addresses

New Company Mileage Policy (Effective 4/1/2021): Chuze Travel & Expense Policy

Important Information for Filling out this Form:

Standard Daily Miles: Roundtrip miles from your Home Address to your Home Club.
Mileage will be reimbursed in excess of the usual round trip commuting mileage to their ordinary work location. Employees who do not have a specific home club will be assigned one to ensure they are being compensated fairly for mileage incurred.
Please be sure that the dates entered are within one pay period.
Please only enter one day per line in the log below.
Mileage is due at the end of each pay period (no later than 10 am PST on Payroll Mondays) and will be paid on the following check.

If you have any questions about this form please reach out to payroll at payroll@chuzefitness.com

Employee Name*

First NameLast Name

UKG Employee ID or Badge #*

Email*

example@example.com

Department*

Business Unit*

Home Address*

Pay Period Dates-please be sure all dates listed are within the pay period selected, and submit only one entry per pay period*

Standard Daily Miles*

Mileage Log - please only include the number of miles and not the word "Mileage"*

	Date (MM/DD/YYYY)	All Destinations in the Day	Reason for Trip	Total Miles Driven in Day (Number Only)
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Your Manager's Name*

Your Manager's Email*

example@example.com

I Attest that my mileage submission is complete and accurate*

First NameLast Name