Department of Health
Travel Voucher Form
State Employee
Non-State Employee
Instructions & Help Mileage Map
First Name Last Name Employee Number Advance Expense License Plate No. Home Station
Subtotals
Purpose of Travel:
GRAND TOTAL
Apply To Advance
AMOUNT REIMBURSABLE
Date Description of Travel
 (Please include the name of every town visited) 
Time Auto
Miles
Trans
Cost
Meals Lodging Miscellaneous
Expense
 
From: To:
Misc:
Leave:
Return:
NCOC NC
 
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NCOC NC
 
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NCOC NC
 
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NCOC NC
 
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NCOC NC
 
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NCOC NC
 
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NCOC NC
 
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NCOC NC
 
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
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NCOC NC
 
From: To:
Misc:
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NCOC NC
 
From: To:
Misc:
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NCOC NC
 
From: To:
Misc:
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Return:
NCOC NC
 
From: To:
Misc:
Leave:
Return:
NCOC NC
Meals - Only Claiming(OC) Breakfast
Lunch
Dinner
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Trip Options
Was this an In-State or Out-of-State Trip?
In-State Trip  Out-Of-State Trip 
Did you Fly?
Yes  No
If you drove a vehicle on your trip please select:
State Car
Private Car
Low Miles  High Miles
License Plate No.

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