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Out-of-State Travel Authorization

First Name: *

Last Name: *

Email: *

County/Department: *

Supervisor: *

Destination: *

Departure Date: *

Return Date: *

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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