Reimbursement Request

Travel Reimbursement Request Form
Please note this form is only for employees in units supported by Executive Office Shared Services (EOSS)
Traveler/Claimant Information
Name

First Name Last Name
Date Prepared
UW Affiliation
Affiliated UW Department/Unit
UW E-mail
example@uw.edu
E-mail
example@domain.com
Home Station

Street Address

Street Address Line 2

City State
Duty Station

Street Address

Street Address Line 2

City State
Address (for Non-UW)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preparer Information
Preparer and traveler same person?

Yes No
Preparer's Name *

First Name Last Name
Preparer's Email *

Trip Information
Purpose of Trip
Include destination city and state, name of event (no acronyms), official dates of event and budget # to charge (if known).
Was destination domestic or international?

Domestic International
Did Trip Include Personal Time?

Yes No
List dates that personal time began and ended
Budget Number *
TOP Codes

Travel Reimbursement Request Form