(Reference Section: Policy and Procedure Section 6.1)

Board Member Information:
First Name:	Last Name:	Board Position:
Work Phone:	Fax No:	Cell Phone:
Reason for trip:

Itinerary:
Destination(s):	Departure	Preferred Time	Actual Time	Airline Flight Number	Confirmation Number
Day	Month	Year	Depart	Arrive	Depart	Arrive

Transportation:
Car required?	Yes	No	From:	To:
Reason:

Accommodation:
Hotel preference:	From (Date):	To (Date):
Confirmation No.
Confirmation No.
Confirmation No.
Confirmation No.
Confirmation No.
Smoking room?	Yes:	No:

Board Member Signature:
Signature:	Date:
I acknowledge my obligation to account for expenditures in connection with this trip and agree to submit expense reports within ten (10) days after my return. I hereby authorize and agree that in the event that I fail to comply with these obligations, the CIC will not reimburse for any amount not accounted for.

Board Chairman Authorization:
Signature:	Date:

Description: