Air Travel Request Form Please fill out the Passenger section completely. ALL fields are required to set up an airline travel rewards account. A travel rewards account (World Perks, American Awards, etc.) will be set up for you for all District related travel according to District Policy 3136 and MN Statute 15.435. THIS SECTION TO BE COMPLETED BY THE EMPLOYEE/PASSENGER ISD 709 Employee Passenger Information (Print your name as it appears on your picture identification) ___________________________ _____________________ ______________________________________________________ First Name

Middle Name

Last Name

___________________________ ____________________________________________________________________________

Date of Birth

Emergency Contact (Name/Phone Number)

Contact Information: _______________________________________________________________________________________

(How can the airline contact you for changes? Cell phone number, hotel number, etc.)

Non-ISD Employee Passenger Information (Print name as it appears on picture identification) ___________________________ _____________________ ______________________________________________________ First Name

Middle Name

Last Name

___________________________ ____________________________________________________________________________

Date of Birth

Emergency Contact (Name/Phone Number)

Contact Information: _______________________________________________________________________________________

(How can the airline contact you for changes? Cell phone number, hotel number, etc.)

Flight Preferences Information (You may search for flights and if you have specific flight preferences attach a copy of the data, but DO NOT book your own flights! Also, there is no guarantee that those exact flights will be booked.) Departure Information

Return Information

Departure Date: _________________________________ Departing From: ________________________________ Destination: ____________________________________ Leave by (time): ________________________________ Time Due @ Destination: _________________________

Return Date: ___________________________________

There is a minimum 21 day advance purchase required by District Policy 3136. Airfare is generally lower if you stay over on a Saturday and may be required. Please note that all flights are non-transferable and non-refundable.

Returning From: ________________________________ Return Destination: ______________________________ Leave by (time): ________________________________ Time Due @ Destination: _________________________ Seat Preference: ________________________________

Authorization Information and Signatures Budget Code: __________________________________________________________ _________________________________

Employee/Passenger Signature

_________________________________ Fund Manager Signature

_________________________________ Director Signature

FOR BUSINESS SERVICES USE ONLY: Airline/Travel Reward No.: _____________________________________________________________________________________ Amount: $________________ Date Booked: ___ /___ /___ Miles Earned: _____________________________ Notice: You have been assigned a District Airline Travel Rewards Number (World Perks/American Awards/etc.). All District related travel miles must be credited to your District account that has been established, according to District Policy 3136 and Minnesota Statute 15.435. Miles earned during District paid travel can not be credited to a personal account.

Form 3136-A

(Rev. 8/07) Item # 35-05-003540

White: Business Services

CanarY: Fund Manager

Pink: Applicant