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*
Enter Email Confirm 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*
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.
- If traveling with another person (staff/volunteer) I agree to wear a mask while in the vehicle.
- I agree to use all protective measures when interacting with client(s) — wearing a mask when indoors, 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.
Phone
This field is for validation purposes and should be left unchanged.

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