U. W. Form 17. 4-39-10M 
THE UNIVERSITY OF WISCONSIN 
Travel Expense Form 
Use Ink, Indelible Pencil or Typewriter 
See reverse side for travel regulations          Madison, Wis.   Date- -
 Ah. .11.---------- 19_]10_ 
Account of ', N  *amerstrom ir.             . 2                 Address 
PURPOSE OF TRIP-------------------------------------Receipt 
Number 
111fmr     fgas & Oil 
PFb.      20   40   Vic. of Piailfinid               20 
1.5 gal. gas                                .30                         30

21        via. of Plainfield               6T 
14.  gal. gaS                               .96                         96

2ic. of Plainfild                          56 
4.2 gal. gas                                .84                         84

23        Vic. of Plainfield               62 
4.7 gsl. gas                                .94                         94

P14       ViC. of Pla    fieaU            35 
2.5 fal. Pa&                                .5                      
   5 
24        Vic. of Plainfield               57 
25           '96 
26              '        425 
13.5gal. gas                               2.75          4          2   75

5        Plainfield to    Madison        93 
via Poynette to attnnd 
r6qul rs. f    inar 
6.5 gal. gas. I qt. oil                    1.4s          5          1   4s

28        Madison to 2Ulainfield 
via Poyuette                    93 
5.6 gal. gns, 1 qt.oil                     1.37          6          1   37

29        Vic. of Plainfield               66 
4-7 gaRl. gas,                              9                          98

Car allowance for mouth                                              30 
 00 
Total                           55   24 
Audited  For  $  ---------by -------------------------- 
Approved ----------------------------------------- Div. 3 Aril kture -------------------------------------

Dept. V4ldlifi 4n     _      .. Req. 
Approved -----------------------------------------Class _    L     ----------------
Dept. $. 
Fund  --   ........................... A ctivity  hR 
STATE OF WISCONSIN, 
County of -----------------------------------------------------------, being
duly 
sworn, says that the within  account of services and daily expenses amounting
 in  all to --------------------------------- 
dollars, is just, correct and true; that the sums charged were actually disbursed
by him for the State of Wisconsin, as 
stated in the account, and that no part of the same has been paid for. That
no part of the expenses of travel herein 
charged for has been had upon a free pass or free transportation of any nature
whatever, and the amount herein charged 
as a disbursement for transportation or for other expenses incident to travel
has been actually paid out. 
Subscribed and sworn to before me this 
day  of,                                  . .1  ..    ..  ...   ...  ...
  ...  ...   ..-------------------------------- 
Notary Public.