Carlson Building Maintenance
Per Diem Request		${date}
• This form is to be submitted by District Managers only. • Forms submitted by anyone else will not be processed. • Fill out all applicable fields highlighted in yellow. Incomplete forms will be returned and reimbursement will be delayed. • Submit one form per employee. Forms with multiple employees will be returned and reimbursement will be delayed. • Requests for Per Diem/Mileage will be processed once per week by the Finance Department • Requests must be submitted by Tuesday at 12:00 PM for the previous calendar week • Requests received after 12 PM Tuesday will be processed the following week. • Special notes are required for irregular circumstances
employee information
EMPLOYEE NAME		${employeeName}
EMPLOYEE NUMBER		${employeeNum}
DISTRICT MANAGER		${dmUserFirst} ${dmUserLast}
JOB SITE
store location		${location}
city		${city}
state		${state}
hotel
first night needed		${firstNight}
last night needed		${lastNight}
per diem				FOR OFFICE USE ONLY
ARRIVAL DATE		DEPARTURE DATE		amt
${arrivalDate}		${departureDate}
mileage				FOR OFFICE USE ONLY

${perDiemInfo}

date	departed from	destination/store	rt/ow	mi	amt

notes
${comments}
FOR OFFICE USE ONLY
GRAND TOTAL
REVISED 02/01/2016