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___-Ji-)
       4 ----------- 19_t1a 
Account of   .   .        tiom    J"                               
   Address 
PURPOSE OF TRIP-------------------------..Receipt 
Number 
23 40    Vic. of    ?1lnfield 
4.-5 g.al    s                  6. 90                                   
     90 
214       Vie. of Plai'ftield 
3.3 g~~. gSa. I oil              391                                    
     91 
25       VITI. Of I'ani~ 
2       Vic. of P'nInfield 
10.2 gal. gs                     131           2.04             1       
      04 
29       Vie. of Plainfield 
:?.9 gal -   as37-95 
30       Vie. of P1a      --f TeL 
11.     1i ~s         oil        16 c.b)                        2 
31      Vc. of '11bck 
. 5 gal..gs                      66          _                          
      90 
Car Allowax    e for month                                              
  30 00 
Total                            50    16 
Audited For $  ---------by 
Approved -----------------------------------------     Div.    a   w   'ltm
----------------------------------- 
Dept.             vt- - - aa g ---   eq $ 
Approved    ------------------------------------------Class         -   
---------------- pDept. - 
Fund -3U ------------------------ Activity.lesM4t,_- 
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 ...--      ---------        -      , A. D. 19.------------------------------

Notary Public.