Revised 2/97 UNITED STATES PROBATION OFFICE
TRAVEL REQUEST FORM
(Submit no later than 14 days prior to requested travel)
Date: _____________________
Name: __________________________________________________________________________
Address: _______________________________________________ Zip Code: ______________
Phone Number: Home: _________________________Work: _____________________________
How long have you been on supervision? _____________________________________________
Are you employed? ________ Yes _______ No Where? __________________________________
Are you on schedule with your fine/restitution payment? _______ Yes ______ No
Balance on fine: _______________________ Balance on restitution: _______________________
Purpose of trip: _______ Pleasure _______ Employment
Destination: ______________________________________________________________________
(City) (County) (State)
Departure Date: ______________________________ Return Date: ________________________
People traveling with you: __________________________________________________________
ACCOMMODATIONS (to be verified): Hotel/Motel: ______ Relatives/Friends: ______
Name: __________________________________________________________________________
Address: ________________________________________________________________________
Telephone Number: Area Code (_______) ___________________________________________
MODE OF TRANSPORTATION: Vehicle Make & Model: _____________________________
License Plate Number: __________________________ Vehicle Owner: ____________________
Airline: Name of Airline: _________________________ Flight No: ___________________
Departure Time: __________ Return Flight No: ___________ Return Time: ____________
Other Transportation- Car rental/friends, etc.: ________________________________________
I UNDERSTAND THAT THIS IS ONLY A REQUEST AND NOT A PERMIT TO TRAVEL
AND THAT A FINAL PERMIT WILL BE ISSUED IF APPROVED.
__________________________________ ___________________________________
Signature Request received by USPO (Date)
