Trip Details
Starting Point: (City, State Zip):
Must provide where your trip started
| Order # | Date | P / D | City, State | Zip | Stop #/ Relay/ Skip | Comments |
Out of Route |
|
| Route Taken | |
| Reason | |
| Approved By | |
OTR Expenses |
|||
Item |
Amt |
Attached |
Paid for By (check all that apply) |
| Permit | |||
| Scales | |||
| Tolls | |||
| Lumper | |||
| Repair | |||
| EQ wash | |||
| Parking | |||
| Other | |||
Note to Office:
EQ Used |
In/Out |
| / | |
| / | |
| / |
Payroll Only
Miles: _________________________________
Stops: ________________________________
Add'l Pay: ____________________________
Add'l Pay: ____________________________
Reimbursements: _____________________
Scheduled Pay Date: __________________
Initials: ________________________________
Driver's Signature:
Date Submitted: