TRAVEL AUTHORIZATION

Mercer University School of Medicine
TRAVEL AUTHORIZATION

***Please attach a copy of the agenda and map for conferences and meetings.
Name*
Date

MonthDayYear
Todays Date
Title*
Dept*
Requestors Email:*
example@example.com
Role at Mercer*
Disposition of work while absent:*
Tenure Status:*
Has your Dean/Chair/Director reviewed and approved your attendance to this conference?*

YesNoNot Applicable
Are you presenting at the conference/meeting?*

YesNo
Are you the lead presenter?*

YesNo
Was the presentation Peer-Reviewed?*

YesNo
Was this an invited presentation?*

YesNo
What is the format of the presentation?*

PlenaryOralWorkshopRoundtablePosterOther
Please list all presenters*
Brief description of presentation:*
On Mercer University School of Medicine Payroll during travel:*

YesNo
Purpose of Travel:*

AdministrativeTeachingResearchCommunity Outreach
Authorized absence to extend from:
Date*

MonthDayYear
Start Date
To*

MonthDayYear
Return Date (Close of business day)
Will this travel be all day:*

YesNo
Departure Time:*

Hour Minutes

AM/PM Option
Estimated Return Time:*

Hour Minutes

AM/PM Option
Destination name & address (Name/Place of conference):*
Explanation: (How will this travel further the mission of MUSM?)*
Is vehicle rental being requested:*

YesNo
Pick Up Date

MonthDayYear
Date
Return Date

MonthDayYear
Date
Is a hotel stay being requested:*

YesNo
Location
Check In Date

MonthDayYear
Date
Check Out Date

MonthDayYear
Date
Source of Funds:
Funding Source:*

General BudgetGrant/Gift/F&AOther
Name of account*
Cost Center*
DG/GR/GF #*
Estimated Cost:
Mileage
Enter total miles driving.
Mileage Reimbursement

Expense Table

	Expenses	Cost ($)
Airfare
Groome
Hotel Accommodation
Meals (Total)
Registration Fee (Seminars)
Vehicle Rental
Other expenses (Uber/Lyft/Train etc.)

Total Cost ($)
Chair or Department Head Email:*
example@example.com
Items to be attached include map, agenda, estimated travel costs (air fare, hotel, registration fee) and presentation acceptance letter.

Cancelof
Should be Empty: