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Out of State Travel Authorization Form

* items in orange indicate required fields

First Name:

Last Name:

Email:

County/Department:

Supervisor:

Destination:

Departure Date:

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( mm/dd/yyyy i.e. 08/31/2006 )

Return Date:

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( mm/dd/yyyy i.e. 09/04/2006 )

Purpose of Trip:

Source of Funds (check all that apply):

	State Appropriated Funds
	Federal Funds
	County Funds
	Grant Funds

Estimated Cost:

Transportation	$
Lodging	$
Registration	$
Other	$
TOTAL	$

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