SAMPLE
XYZ Charter
719
555/555-1234
TRANSPORTATION REQUEST
Date: ________________________ Campus: _______________________________
Departure Return
Place: ________________________ Place:
__________________________________
Date: ________________________ Date:
__________________________________
Time: ________________________ Time:
__________________________________
Number of
Passengers: _____________________
________Bus(es) for ________ miles @ $1.00 per mile (seats 72) $________
________Mini-bus(es) for _______ miles @ $1.00 per mile (seats 24) ________
________Other type of vehicle _____ miles @ _____ per mile ________
Due to the limited number of school vehicles,
requests will be handled on a first come, first serve basis. Please turn in your requests as early as
possible. Check with the central office
to confirm arrangements several days prior to trip.
Destination (city
and state): ____________________________________________________
Date(s) of trip: _______________________________________________________________
Purpose of trip: ______________________________________________________________
Other passengers: ____________________________________________________________
I affirm that the
amounts above are true and correct.
Claimant: _____________________________________
Date: ________________________
Home Address: ______________________________________________________________
Supervisor: ______________________
Date: ___________ Principal: __________________
Business Manager: ____________________
Date: __________________________________
Student Travel: _____________________________
$________________________________
Fund Account Code Amount
Purchase order number ___________________________________________________
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