Name: ________________________________________________________________________________

Destination: _________________________________________________________________________

Purpose: _____________________________________________________________________________
                 (Committee Name, Speaker, etc.)

Dates: _______________________________________________________________________________

Expenses

     Transportation
          Air -- attach receipt or ticket stub                    ____________________
		  
          Automobile -- __________ miles @ 50.5¢/mile             ____________________
		  
          Taxi, Metro, limo, etc.                                 ____________________
		  
          Parking                                                 ____________________

     Hotel -- attach receipt                                      ____________________

     Meals -- itemize separately and attach receipts              ____________________

     Honorarium                                                   ____________________

     Other -- specify                                             ____________________

     TOTAL EXPENSES                                               ____________________



_______________________________________             Make check payable to:
Signature                                           (print your name and address)


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