Request for Governor S Approval For

UT Tyler Request for Travel Approval to Foreign Countries

This form is required for foreign travel to a destination that is NOT in the U.S., a possession of the U.S., Mexico, or Canada.

Form must be completed at least 30 days prior to travel.

1) Name: / RTA:
2) Departure Date: / Return Date:
3) Complete registration with International SOS at
http://www.uttyler.edu/finserv/uttylerfinancialservicestravelsosintro.html. / Check if completed

4) Major Destinations: City, Country

5) Primary Business Purpose of Travel: If additional space is required please attach.
6) Benefit of Travel to U T Tyler: If additional space is required please attach.
7) Estimated Travel Expenses: / § Air Transportation / $
§ Ground Transportation / $
§ Lodging / $
§ Meals / $
§ Registration Fees / $
§ Other / $
Total Expenses / $
8) Source of Funds: (show all accounts to be charged) / Account Number / Budget Authority / OSR Approval
Grant Funded
□ Federal—accounts begin with #26 (Fly America Act applies)
□ State—accounts begin with #14 or #26 (appropriated)
□ Foundation/Corporate/Other Private— accounts begin with #26 or #30
Internally Funded
□ State—accounts begin with #14 (appropriated)
□ Local—accounts begin with #19 or #30 (designated tuition/fees or gifts)
□ No cost to University
9) “I hereby certify that the purpose of this trip is official University business and is necessary for the proper performance of this University's statutory functions. I further certify that I am aware of any travel advisory issued by the United States Department of State regarding a warning against or restriction on travel to the destination of this trip, and am aware of the potential risks associated with travel to that destination.”
Signature of Traveler / Date / Traveler’s Title and Department
Signature of Department Chair / Date / Signature of Dean/Director / Date
Signature of Appropriate Vice President / Date / Signature of President / Date

ALL SIGNATURES ARE REQUIRED.

Please return signed form to the traveler. The form must be attached to the reimbursement request.

3/19/10