Payee Name
Home Address Department Use Only
Cost Center No. Object
NORTHLAND COMMUNITY & TECHNICAL
COLLEGE NON-STATE EMPLOYEE
REIMBURSEMENT REPORT
Vendor No.
Other
Total Fare Reimbursable Total
Date Reason for Reimbursement Itinerary Trip Trip and Meals Lodging Air, Expenses Daily
Time Location Miles Local MI. B L D RR, Bus (Itemize) Expenses
Departure
Arrival
Departure
Arrival
Departure
Arrival
Departure
Arrival
Departure
Arrival
Departure
Arrival
Departure
Arrival
All Expense Reports Must Be Signed Total Enter Total Mileage Expense
Total Mi. Rate Subtotal
Total Trip & Local Total Expenses
Non-State Employee Signature Date Phone
Authorized Departmental Signature Date Work Phone
I declare under the penalties of perjury that this claim is just and
correct and that no part of it has been previously reimbursed to me.
Approved: Based on knowledge of the necessity for travel and other expenses and on the
basis of compliance with all provisions of Northland Community & Technical College's
Regulations.
116012
2450
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