This form is used to calculate the mileage and fuel costs incurred by an employee during official duty.  The distance covered is documented and verified in order to be able to reimburse the employee. The form is pretty simple and easy to fill out because of its clear cut format.

Company name: _______________________________

Company logo: ________________________________

Address: _____________________________________

Employee name: _______________________________

Employee ID no: _______________________________

Job title: ______________________________________

Department: ___________________________________

Tel: __________________________________________

Mobile: _______________________________________

Email: ________________________________________

Signature: _____________________________________

Expense authorized by: ___________________________

Department: ____________________________________

Signature: ______________________________________

Date mileage expense incurred:

From: __________________________________________

To: ____________________________________________

Description of vehicle used:

Make: __________________________________________

Vehicle registration: _______________________________

Please indicate details of mileage costs incurred:

Date:

________________________________________________

Starting mileage:

________________________________________________

Reason for traveling:

________________________________________________

Ending mileage:

________________________________________________

Cost of mileage expense:

________________________________________________

Date:

________________________________________________

Starting mileage:

________________________________________________

Reason for traveling:

________________________________________________

Ending mileage:

________________________________________________

Cost of mileage expense:

________________________________________________

Total amount of mileage cost in USD:

________________________________________________

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