CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA
AUTHORIZATION TO TRAVEL ON STATE BUSINESS
NAME OF TRAVELER _____________________________________________ TODAY’S DATE ___________________
HOME ADDRESS _______________________________________ ____________________ ________ ____________
Street City State Zip
WORK ADDRESS _____________________________ _________________________________ ________________
College/Department email address Extension
PURPOSE OF TRAVEL: _____________________________________________________________________________
EXPECTED TRAVEL EXPENSE: ______________________ + _______________________ = _____________________
Paid by Cal Poly Traveler/Others to Pay Total Expense
EXPECTED LODGING $ __________________________ _____________________________________________
Indicated Amount Approved by President/President’s designee
JUSTIFICATION FOR LODGING EXPENSE EXCEEDS ALLOWED AMOUNT: ____________________________________________________
_________________________________________________________________________________________________
DATES OF OFFICIAL STATE BUSINESS From___________________________ To _________________________
Date and Time Date and Time
DATES OF PERSONAL TRAVEL From___________________________ To _________________________
Date and Time Date and Time
DESTINATION(S) ____________________________________ TRAVELING BY ________________________________
Air, Automobile, Etc. *
I certify that the above information is true and correct.
A. Certication of Minimum Liability Insurance Requirements and Condition of Vehicle
I certify that I have liability insurance in at least the following amounts: $15,000 for personal injury to, or death of, one person, $30,000 for personal
injury to two or more persons in one accident, $5,000 for property damage. I further certify that my vehicle is adequate for the work performed,
equipped with seat belts and in safe mechanical condition; that a current Privately-Owned Vehicle Insurance Certication Form STD 261 is on
le with my supervisor; and that any accident which may occur while the vehicle is being operated on State business will be reported within 48
hours on Form STD 270. I have satisfactorily completed a CSU Approved defensive driving course. I am in possession of a valid California or
other State driver’s license. I certify that I have not been issued more than three moving violations or have been responsible for more than three
accidents (or any combination of more than three thereof) during the past twelve month period.
________________________________________________________________
Traveler Signs Here
Name of person preparing form if different than traveler_________________________________ Extension _______________
THE PERSON NAMED ABOVE HAS BEEN APPROVED FOR STATE TRAVEL AS DESCRIBED.
Approved by (Name) Title Signature Date
_____________________________ __________________________ __________________________ __________
_____________________________ __________________________ __________________________ __________
_____________________________ __________________________ __________________________ __________
FUNDING SOURCE - PEOPLESOFT CHARTFIELD STRING
ACCOUNT(6 DIGITS) FUND(6 DIGITS) DEPT. ID (5 DIGITS) PROGRAM (4 DIGITS) CLASS*(5 DIGITS) PROJECT*(5 DIGITS) Amount Approval
ACCOUNT(6 DIGITS) FUND(6 DIGITS) DEPT. ID (5 DIGITS) PROGRAM (4 DIGITS) CLASS*(5 DIGITS) PROJECT*(5 DIGITS) Amount Approval
ACCOUNT(6 DIGITS) FUND(6 DIGITS) DEPT. ID (5 DIGITS) PROGRAM (4 DIGITS) CLASS*(5 DIGITS) PROJECT*(5 DIGITS) Amount Approval
* When CLASS field IS C2XXX, then PROJECT field must be same as CLASS field
FOR UFS USE Voucher #
F-2963-08 Rev. 04/18
/per night
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