Request to Travel In-state for UMaine Extension Staff

Please complete this form. A copy will automatically be submitted via email to your immediate supervisor for approval. Your supervisor is responsible for then submitting the form to the appropriate Program Administrator or Dean for their review and approval.

Extension Staff Member Name (person traveling)*
First Last
Extension Staff Member Email*
Supervisor's Name*
First Last
Supervisor's Email*
Starting Point for traveler*
(physical address with number, road, town in Maine)

Street Address Address Line 2 City State ZIP Code
Destination*
Name of Business (Please indicate "Farm" or "Home" if there is no business name) Contact Person
Destination Address*
(physical address with number, road, town in Maine)

Street Address Address Line 2 City State ZIP Code
Date of planned travel*
Date Format: MM slash DD slash YYYY
Purpose of planned travel (justification in 200 words or less)*
In-state travel will only be permitted if all other options are not feasible.
Terms of Acceptance*
You must agree to all terms.
- I agree to travel solely (no other persons in the vehicle).
- I agree to use all protective measures in interacting with the client(s) — proper distancing from people — 6 feet, no physical contact, proper use of PPE (gloves, face mask, footwear), and disinfecting of footwear when necessary.
- I will use proper sanitation of my hands and clothing following the visit.
Electronic Signature:*
Please type your First and Last Name
*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Name of Business (Please indicate "Farm" or "Home" if there is no business name)	Contact Person