TRAVEL AUTHORIZATION REQUEST
CO-112 REV.7/08
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
Use this form for travel requiring prior approval.1.
2.
For identification of requests, please assign a separate
number to each Request form, and enter it under block 2 T.A.
Number
3.
(1) DATE OF REQUEST
(2) T.A. NUMBER
(3) BUSINESS UNIT NAME & ADDRESS TO WHICH FORM SHOULD BE RETURNED (Include Zip Code) BUSINESS UNIT NO. TELEPHONE NUMBER (Business Office)
DISTRIBUTION :
ORIGINAL- (UNION FUNDS ONLY) - COMPTROLLER'S, FISCAL POLICY DIVISION, TRAVEL UNIT
COPY - AGENCY BUSINESS OFFICE & EMPLOYEE
DATE
DATE
DATE
OFFICE OF THE STATE COMPTROLLER
(Authorized Signature/Date)
(33) AUTHORIZED BY (Business Unit Head or Authorized Agent))
(32) APPROVED BY (Supervisor, Div. Head, Director, Dean etc.)
(31) SIGNATURE OF EMPLOYEE
(4) EMPLOYEE NAME (FOR WHOM AUTHORIZATION IS REQUESTED) (5) EMPLOYEE NUMBER (6) TITLE
COLLECTIVE
BARGAINING
IDENTIFICATION
(7) SPECIFY BARGAINING UNIT NUMBER , MANAGEMENT OR OTHER
NP-1
NP-2
NP-3
NP-4
NP-5
NP-6
P-1
P-2
P-3A
P-3B
P-4
P-5
OTHER (Specify)
(8) WORK TELEPHONE NO. (Include extension no.)
(9) HOME TELEPHONE NO. (10) OFFICIAL DUTY STATION (Give complete address)
(11) (12)
ITINERARY
HOME
TO
DATES
FROM TO
(13) MISCELLANEOUS INFORMATION (Actual
time of departure from home and return to
home).
Parking Permit Requested?
YES NO
(14) OBJECT AND NECESSITY OF TRAVEL (Attach substantiating documents)
(15) TYPE OF TRANSPORTATION
(16) TOTAL COST (Itemize) NOTE; RATES FOR MEALS AND LODGING SHOULD NOT EXCEED THOSE PROVIDED FOR IN STANDARD TRAVEL REGULATIONS AND IN COLLECTIVE BARGAINING AGREEMENTS.
AIR RAIL STATE OWNED CAR RENTAL CAR PERSONAL CAR OTHER
(Specify)
AMOUNT QUANTITY
.
(20)
GL UNIT
(18) (19) (21)
BUDGET
DATE
(22)
DEPARTMENT
FUND
SID
(23)
PROGRAM
(24) (26)
ACCOUNT
PROJECT/
GRANT
CHARTFIELD
1
(25) (27)
CHARTFIELD
2
BUDGET
REFERENCE
AIRFARE
LODGING
CONFERENCE HOTEL
MEALS
TAX
GRATUITIES
PERSONAL MILEAGE
WITH RIDER:
TAXI(S)
(
MI@
RATE
)
REGISTRATION FEE
RAIL
OTHER
(17)
TOTAL COST
(28)
(30)
(29)
MANAGEMENT
REFERENCE
RIDER(S) TA #
OTHER
STATE
STATE
ORIGINAL - (NON- UNION FUNDS) - AGENCY BUSINESS OFFICE
COPY - EMPLOYEE
If requesting reimbursement from Union Travel Funds,
forward a complete set to the Office of the State
Comptroller, Fiscal Policy Division, Travel Unit, 55 Elm
Street, Hartford, CT 06106-1775. When Department
funded, retain copy for audit purposes.
$0.00
$0.00
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