TRAVEL & ENTERTAINMENT REIMBURSEMENT REPORT Page 1

NAME (PLEASE PRINT) DEPT. LOCATION

REASON/BUSINESS PURPOSE FOR EXPENDITURE SPONSORING ORGANIZATION

TYPE OF EXPENSE Sunday Monday Tuesday Wednesday Thursday Friday Saturday

DATE
Airfare
Meeting Fee
Lodging *
Car Rental
Local Transportation (See Below)
Parking/Cabs
Telephone
Other Expenses
Meals / Entertainment **
TOTAL
Total Expenses, Page 1

If you have additional lodging expenses due to a Total Expenses, Page 2

* savings in airfare expenses, please document the
Total Expenses
original airfare, the actual airfare, and the cost savings.
Please itemize out meals & entertainment expenses on Less Advances
** page 3.
Total Due Employee
Total Due Park Nicollet

LOCAL TRANSPORTATION
DATE BUSINESS PURPOSE LOCATION MILES AMOUNT

Total

I certify that this report accurately describes the actual and necessary expenses incurred by me while engaged in company business.

EMPLOYEE DATE APPROVAL DATE

SIGNATURE SIGNATURE

APPROVAL DATE
SIGNATURE

EMPLOYEE MAILING ADDRESS: STREET STATE ZIP

PAGE 1 of 3—PARK NICOLLET HEALTH SERVICES 15200 (3/2005)

TRAVEL & ENTERTAINMENT REIMBURSEMENT REPORT Cont'd Page 2
TYPE OF EXPENSE Sunday Monday Tuesday Wednesday Thursday Friday Saturday
DATE
Airfare
Meeting Fee
Lodging *
Car Rental
Local Transportation (See Below)
Parking/Cabs
Telephone
Other Expenses
Meals / Entertainment **
TOTAL
Total Expenses, Page 1

If you have additional lodging expenses due to a Total Expenses, Page 2

* savings in airfare expenses, please document the
Total Expenses
original airfare, the actual airfare, and the cost savings.
Please itemize out meals & entertainment expenses on Less Advances
** page 3.
Total Due Employee
Total Due Park Nicollet

LOCAL TRANSPORTATION
DATE BUSINESS PURPOSE LOCATION MILES AMOUNT

Total

PAGE 2 of 3—PARK NICOLLET HEALTH SERVICES 15200 (3/2005)

TRAVEL & ENTERTAINMENT REIMBURSEMENT REPORT Cont'd Page 3
Please itemize business meals & entertainment expenses below and attached detailed receipts:
Date Restaurant/Establishment Date Restaurant/Establishment

Business purpose Business purpose

Attendees Attendees

Food and non-alcoholic amount Food and non-alcoholic amount

Alcohol Alcohol

Other (please specify) Other (please specify)

TOTAL EXPENSE TOTAL EXPENSE

Date Restaurant/Establishment Date Restaurant/Establishment

Business purpose Business purpose

Attendees Attendees

Food and non-alcoholic amount Food and non-alcoholic amount

Alcohol Alcohol

Other (please specify) Other (please specify)

TOTAL EXPENSE TOTAL EXPENSE

Date Restaurant/Establishment Date Restaurant/Establishment

Business purpose Business purpose

Attendees Attendees

Food and non-alcoholic amount Food and non-alcoholic amount

Alcohol Alcohol

Other (please specify) Other (please specify)

TOTAL EXPENSE TOTAL EXPENSE

Date Restaurant/Establishment Date Restaurant/Establishment

Business purpose Business purpose

Attendees Attendees

Food and non-alcoholic amount Food and non-alcoholic amount

Alcohol Alcohol

Other (please specify) Other (please specify)

TOTAL EXPENSE TOTAL EXPENSE

PAGE 3 of 3—PARK NICOLLET HEALTH SERVICES 15200 (3/2005)