Expense Report Request Form

This form should be used by students and guests. Faculty should continue to submit reports using Concur.

History Department Reimbursement and Travel Card Expense Request

Name*
First Last
Status*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Expense Summary
Purchase Method*
Report Type*
Trip Purpose and Destination(s)
Trip Start Date
MM slash DD slash YYYY
Trip End Date
MM slash DD slash YYYY
Reason for Reimbursement
Expense Details
Expenses
Click the + symbol to add additional lines. For foreign transactions, enter prices in original currency.
Expense Description Purchase Date Vendor Price
Are you claiming per diem?
- Yes
- No
Per Diem Rates
Location Dates Total Per Diem Claimed

Maximum domestic per diem rates available here: http://www.gsa.gov/portal/category/104711. Maximum foreign per diem rates available here: http://aoprals.state.gov/web920/per_diem.asp. Per diem for cities not listed must use "Other" rates.
Are you claiming personal car mileage?
- Yes
- No
Mileage Details
Date Starting Address Destination Address Mileage Cost

Mileage cost = number of miles X 0.575
Total Expenses*
The total sum of all expenses claimed above, in US dollars.
Receipts*
- Receipts have been uploaded to Concur.
- I want to upload receipts here.
- Receipts have been submitted in hard copy.
- Not applicable (per diem and/or mileage only)
Receipts can be uploaded to Concur, uploaded to this form, or submitted in hard copy. Hard copy receipts should be taped individually to 8.5 x 11" paper and submitted to Jillian Nichols.
Receipts*
Please upload all receipts here.
Drop files here or

Max. file size: 100 MB.
Any Additional Notes

Expense Description	Purchase Date	Vendor	Price

Location	Dates	Total Per Diem Claimed

Date	Starting Address	Destination Address	Mileage Cost

Expense Report Request Form

History Department Reimbursement and Travel Card Expense Request

Expense Summary

Expense Details