Fillable Yes No Yes No (Los Angeles Unified School District)

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Yes No Yes No (Los Angeles Unified School District)

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Yes No
Yes No
Travel Location:
-
- - -
$
$
$
$
# of Days
$
$
$
$
$
Rental Agency
$
$
$
Yes No
W-West
Conference Title:
Trip Type:
Please select TRIP TYPE from the Drop-Down Menu
Trip Activity:
AM
PM
Is mileage reimbursement being requested?
If yes, please attach map showing distance from school/work to event location.
Start Location:
End Location:
Time
AM
PM
City:
Region/State:
Zip:
Will your personal vehicle be used to get to the destination?
Email:
Direct Telephone:
Work Telephone No:
Certificated
DEPARTURE
Date:
NW-Northwest
S-South
self-paid
520002
RETURN
Name:
Date:
Time
Address:
# of Days
Airfare:
Baggage:
District Paid
# of Days
Per Diem:
P-Card
Parking:
self-paid
Outside Agency ***
District Paid
# of Days
Traveler:
Agency Name
T-Card
Hotel Name:
Form 10.12.1 (rev 01/01/2022)
Hotel:
Approved by:
(Print Name and Title)
# of Full Days
** (If additional approval required) (Print Name and Title)
(Signature)
(Date)
Approved by:
(Date)
** (If additional approval required) (Print Name and Title)
(Signature)
Approved by:
(Date)
Yes
No
(Signature)
(Signature)
Approved:
WBS Element
Fund
Affidavit: I have read and understand the guidelines of Bulletin 5525.3 and declare under penalty of perjury that the foregoing is true and correct.
Cost Center
Comments:
Gasoline:
Car Rental:
Mileage:
T-Card
Business Purpose
Taxi/Shuttles:
Miscellaneous:
Substitute:
TOTAL ESTIMATED EXPENSES: $
Grant
Functional Area
Name (First)
Personnel Number:*
School/Office Name:
T-Card
self-paid
(Last)
Cost Center
Employee Number:
(MI)
self-paid
# of Half Days
(For Rental Cars ONLY)
Conf. Fee:
ESTIMATED EXPENSES:
- -
Imprest
PO/Shopping Cart
# of Days
*** Substitute - Outside Agency: Please indicate the expense budget line used for the substitute:
Meals provided at conference?
Local District Offices Legend:
NE-Northeast
T-Card
District Paid
-
self-paid
T-Card
self-paid
T-Card
self-paid
T-Card
self-paid
Airline:
520002
C - Central
% Distribution
Title:
E-East
Point of contact (SAA for Schools/Travel Site Specialist for non-School based Offices):
TRAVEL & CONFERENCE ATTENDANCE INFORMATION
Order
(Date)
self-paid
Classified
Job Class Code:
Loc. Dist. Office:
General Trip Data:
Fax Telephone No:
LOS ANGELES UNIFIED SCHOOL DISTRICT
REQUEST FOR TRAVEL AND ATTENDANCE AT CONFERENCE, CONVENTION OR MEETING
District Employee
District Parent
Email:
Semi-Monthly
- -
Encumber funds from Expense Budget Line: Funds must be available at the time of entry into SAP.
% Distribution Cost Center GL Order/WBS Element Fund Grant Functional Area
Conference will address needs of (select ALL that apply):
Low Income
EL(English Learner)
Foster Youth
Homeless
RFEPs
Other:
GATE
SEL(Std.Eng.Learner)
0.00
0.00
0.00
0.00
?
Local (within 45 miles of work/home)
Conference-Certificated
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Yes No Yes No (Los Angeles Unified School District)

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Completed 1 March 2022

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