Policy Exception Request Form

Exhibit G

POLICY EXCEPTION REQUEST

Travel Authorization No.             Traveler’s Name                           

Date___________

POLICY EXCEPTION REQUESTED:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

JUSTIFICATION:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

I certify that I am not being reimbursed from another source for any portion of the requested payment.

REQUIRED SIGNATURES:

Employee:_______________________Date___________

Approved by:_____________________Date___________