State of Maryland Travel Desk: DHMH

DHMH AUTHORITY TO INITIATE LODGING RESERVATION

Employee's Name:
(As it appears on government issued photo ID, i.e. driver's license or passport)

Profile Name:

Office Location: Office Phone:

Office Email:

Confirm Email:
(Must be the same as Office Email above)

Home Address:

City: State: Zip Code:

Home Phone: Cell:

Supervisor's Name:

Phone: Fax:

Supervisor Email:

Confirm Email:
(Must be the same as Supervisor Email above)

Backup Approval Contact (If supervisor is unable to respond within 24 hours)

Backup's Name:

Phone: Fax:

Backup Email:

Confirm Email:
(Must be the same as Backup Email above)

Alternate Backup Approval Contact (In addition to Backup Approval Contact above)

Alternate's Name:

Alternate's Phone: Fax:

Alternate's Email:

Confirm Email:
(Must be the same as Alternate Backup Email above)

DETAIL OF LODGING RESERVATION REQUEST(S)

Trip #1 Purpose:

Lodging # of Days: X Estimated Rate: = Total: $

Travel Destination:

Travel Dates From: Travel Dates Through:

Hotel Check In: Hotel Check Out:

Requested Hotel:

Hotel Address:

City: State: Zip Code:

Hotel Phone: Hotel Fax:

Special Requests
or Remarks:

Trip #2 Purpose:

Lodging # of Days: X Estimated Rate: = Total: $

Travel Destination:

Travel Dates From: Travel Dates Through:

Hotel Check In: Hotel Check Out:

Requested Hotel:

Hotel Address:

City: State: Zip Code:

Hotel Phone: Hotel Fax:

Special Requests
or Remarks:

FUND CERTIFICATION & APPROVAL

IMPORTANT: When you click the SUBMIT button below, your request will be sent to the Supervisor Email you entered above. Please be sure you entered a valid email address. Your supervisor will approve or deny the request and notification of the decision will be emailed to you.

Human Verification:

+ 3 = 5

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