Amendment? U. S. DepartmentoftheInterio r bureau foreign Travel Certification Form Date Initiated

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Amendment? U. S. D e p a r t m e n t o f t h e I n t e r i o r BUREAU __________

Foreign Travel Certification Form Date Initiated / /

Traveler's Name, Phone & Fax Number:

Position Title, Grade, Duty Station:

COUNTRY (use + sheets for more than 3)

Major Cities to be visited

Dates of Travel

Purpose of Travel: Reimbursable Agreement (PASA,etc) Official USG Delegate Employee Training/Development

Professional/Scientific Meetings Field Work Other ___

Justification for Travel: Explain objective of trip, role of traveler, importance of trip to Bureau Mission, consequence if travel does not occur, etc.

Costs During Travel Period

Will other donor or employee reimburse cost?____Yes* ______No (If "yes," complete following)

Name of Donor: 1. 2.

Salary $

Salary $ $

Per Diem $

Per Diem $ $

Transportation $

Transportation $ $

Other (Conf.fees, etc.) $

Other (Conf. fees, etc.) $ $



* Use of non-Federal funds requires additional clearances under 31 USC Section 1353.
I HEREBY APPROVE THE TRAVEL AND CERTIFY that the travel proposed is essential and supported by the following considerations. Explain on reverse items not checked below:
1.___ Travel is limited to the minimum necessary to accomplish the agency's program (41 CFR 301);

2.__ Clearance by the US Mission/Embassy has been requested and travel will not occur if US Mission/Embassy objects;

3.__ Traveler will issue a report within ten (10) days of return to be distributed to interested officials to share in the benefits;

4.___ Annual leave of more than one workday is described here or is attached;___________________________________

5.__ No other Bureau employees are known to be traveling to this destination at this time. If not checked, give names of other bureau officials to attend:


(Signature of head of Bureau) (Date)
Approved: Concur:
_______________________________________________________________ ___________________________________________________________________________

(Assistant Secretary) (Date) (Assistant Secretary PMB) (Date)

Form DI-1175

(Rev. Aug. 1994)

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