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PART I: NOMINATION FORM

1. Course Title: 2. Date: 3. Location:

4. Nominee’s Name: (Last, First, Middle Name) 5. Nominee’s Title:

6. Nominee’s Work Phone No.: 7. New Traveler:

 Yes

 No

8. Nominee’s E-mail Address: 9. Program:

 Title IV - AML

 Title V - Regulatory

10. Name of Agency:

11. Official Duty Station: (Complete Overnight

mailing Address)

Miles to training site: 

12. Residence: (City and State)

Miles to training site:

13. Supervisor’s Name: 14. Supervisor’s E-mail Address:

15. Supervisor’s Mailing Address: 16. Supervisor’s Telephone Number:

PAPERWORK REDUCTION ACT STATEMENT

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or

sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control 

number. This information is being collected to calculate the type and number of classes and instructors needed to complete

OSM’s technical training mission, and to estimate costs for our annual budget. We do not use the information for any other

internal secondary purpose.

Public reporting burden for this form is estimated to average 5 minutes per response, including the time for reviewing the 

instructions, gathering and maintaining data, and completing and reviewing the form. Response is required to obtain a benefit. 

Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, 

OSM, Room 202 SIB, 1951 Constitution Ave, NW, Washington, DC 20240. 

UNITED STATES DEPARTMENT OF THE INTERIOR

Office of Surface Mining Reclamation and Enforcement

NOMINATION and REQUEST FOR PAYMENT FORM for

OSM TECHNICAL TRAINING COURSES

OMB 1029-0120

Expiration Date: 
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PART II : REQUEST FOR REIMBURSEMENT OF TRAVEL AND PER DIEM EXPENSES

(Please note: Only complete this part if you are seeking reimbursement)

17. Requested Mode of Travel:

Government-owned Vehicle Common Carrier (air) Rental Car

Privately Owned Vehicle Other (specify)

 IF PRIVATELY OWNED VEHICLE (POV) IS CHECKED ABOVE, PLEASE CHECK ONE OF THE FOLLOWING. 

THIS WILL DETERMINE THE MILEAGE RATE FOR POV USAGE.

 Individual has no access to a government vehicle

 Government vehicle available in pool and individual chooses to use POV

 Government vehicle assigned to individual and individual chooses to use POV

Closest major airport & miles to/from Residence:

One Way:

Closest major airport & miles to/from Office:

One Way:

18. Per Diem Requested For:

 Lodging Beginning Date: Ending Date:

 Meals and Incidentals

19. Fund Request:

We do not have funds available to pay travel and per diem expenses for the above nominees because:

 Sufficient funds were not made available through legislature’s appropriation process.

 As a practice, the State does not provide out-of-state travel authority for the purpose identified above.

 Letter attached.

 Other (please explain briefly):

Please note: Nominations will be accepted only if they are submitted by the Training Contact in 

your State, Tribal, or OSM office. Additionally, to be accepted, nomination must be signed by your 

supervisor.

Authorized Signature