U.S. DEPARTMENT OF THE INTERIOR BUREAU\_\_\_\_\_\_

**Foreign Travel Certification Form** Date Initiated\_\_\_\_\_\_\_

  -----------------------------------------------------------------------
  Traveler\'s Name, Phone & Fax Numbers, & e-mail:

  Position Title, Grade, Duty Station:
  -----------------------------------------------------------------------

  ------------------------ ------------------------ ----------------------
  **COUNTRY (use + sheets  **Major Cities to be     **Dates of Travel**
  for more than 3)**       Visited**                

                                                    

                                                    

                                                    
  ------------------------ ------------------------ ----------------------

+---------------------------------------------------------------+------+
| **Purpose of Travel:** G Reimbursable Agreement (PASA, etc.)  | **Bu |
| G Official USG Delegate G Employee Training/Development       | reau |
|                                                               | C    |
| > G Professional/Scientific Meeting G Field Work G Other      | lear |
|                                                               | ance |
| **Justification for Travel:** Explain objective of trip, role | and  |
| of traveler, importance of trip to Bureau Mission,            | Con  |
| consequence if travel does not occur, etc.                    | trol |
|                                                               | N    |
| In Country Contact:                                           | umbe |
|                                                               | rs** |
|                                                               |      |
|                                                               | *    |
|                                                               | For* |
|                                                               | Bu   |
|                                                               | reau |
|                                                               | *Use |
|                                                               | On   |
|                                                               | ly:* |
+---------------------------------------------------------------+------+

*\* Use of non-Federal funds requires additional clearances under 31 USC
Section 1353.*

  ------------------- ---------------------------------------------------
  Costs During Travel Will other donor or employee reimburse cost? Yes\*
  Period              No (If \"yes,\" complete following)

                      Name of Donor: 1. 2.

  Salary \$           Salary \$ \$

  Per Diem \$         Per Diem \$ \$

  Transportation \$   Transportation \$ \$

  Other \$            Other (Conf. Fees, etc.) \$ \$

  TOTAL \$            TOTAL \$ \$
  ------------------- ---------------------------------------------------

*\* Use of non-Federal funds requires additional clearances under 31 USC
Section 1353.*

+-----------------------------------------------------------------------+
| I HEREBY APPROVE THE TRAVEL AND CERTIFY that the travel proposed is   |
| essential and supported by the following considerations. Explain on   |
| reverse items not checked below:                                      |
|                                                                       |
| 1\. Travel is limited to the *minimum necessary to accomplish the     |
| agency\'s program* (41 CFR 301);                                      |
|                                                                       |
| 2\. Clearance by the US Mission/Embassy has been requested and travel |
| will not occur if US Mission/Embassy objects;                         |
|                                                                       |
| 3\. If required, traveler will issue a report within ten (10) days of |
| return to be distributed to interested officials to share in the      |
| benefits;                                                             |
|                                                                       |
| 4\. Annual leave of more than one workday is described here or is     |
| attached:                                                             |
|                                                                       |
| 5\. No other Bureau employees are known to be traveling to this       |
| destination at this time. If not checked, give names of other bureau  |
| officials to attend:                                                  |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| (Signature of Head of Bureau) Date                                    |
+-----------------------------------------------------------------------+

Approved: Concur:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Assistant Secretary , if applicable) (Date) (Director, PPA/PMB) (Date)

DOI Form 1175

Updated 1/08