Rajiv Gandhi Institute of Petroleum Technology

Rae Bareli

Tour Claim Form

G.A.R. 14-A [See rules 66 (1) and 90 (1)(i)]

PART- A (To be filled up by claimant)

Name: Dr./Mr./Ms. Pranshu Dixit
rd
Designation: Student ( B.Tech 3 Year EChE17037)
Basic Pay: ` N/A per month
Grade Pay: ` N/A per month
Purpose of Journey (s) performed: AIChE Regional Student Conference

PARTICULARS OF JOURNEYS AND HALTS

Flight/Train
Mode of Distance Fare Duration of
Departure Arrival Class Ticket PNR
Journey in Kms. (`) Halt
No.
Station Date & Time Station Date & Time Days Hrs.
Lucknow 29/08/19 13:05 Mumbai 29/08/19 15:30 Air Economy 1376.4 3446 GCJLNY

Mumbai 30/08/19 7:00 Pune 30/08/19 10:30 Bus 150 460

AM AM
Pune 30/09/19 7:00 Mumbai 30/08/19 11:30 Bus 150 460
PM PM
Mumbai 1/09/19 10:45 Lucknow 1/09/19 13:05 Air Economy 1376.4 3402 0 0 L3HKWY

Total Fare (7768 INR)

(1) Total Fare: ` 7768/- INR /-.Tickets purchase by RGIPT, if yes, please tick (√)
(2) Road/Taxi: Kms. @ ` _per kms. = _
(Mode of conveyance used i.e. by Government transport/ by taking a taxi, a single seat in a bus or other public conveyance/ by
sharing with another Government servant in a car belonging to him or to a third person to be specified) Maharashtra Govt Bus

(3) Hotel Expenses: ` /- @ ` per day (Enclosed bills in original)

Accommodation (Hotel / Guest House /Other) availed: From To .
Total day’s availed . (Particular to be furnished along with hotel receipts etc. providing board & lodging at scheduled
tariffs)

(4) Other actual expenses incurred: ` 999/- ( Registration Fee) (Attached documents)

(5) Amount of T.A. Advance, if any, drawn: ` 0 (Attached approvals)

Total Claim (1 + 2+ 3 + 4 - 5) ` 8767 /- (In words Eight Thousand Seven Hundred Sixty Seven)
(Certified that all parts of the journey have been performed in accordance to the CERTIFICATE given below)

CERTIFICATE
Certified that I have actually travelled in the class to which I am entitled. It is also certified that I did not perform the road
journeys for which the mileages have been claimed at the higher rates. In case of hiring taxi, it is also certified that claim is
as per my entitlement.

Date: 03/10/209 _ Signature:

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