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___________