Form 3170-XXXX CFPB Travel Form

OMB Control Number: 3170-XXXX
Expiration Date: XX/XX/XXXX

Travel Information Form
Traveler
Last Name: __________________________________________
First Name: __________________________________________
City of Residence: ____________________________________

Emergency Contact
Name: ________________________________________________
Telephone: ________________________________

Trip Information
Departure Date: _____________________

Preferred Departure Time: _______________

Departing from (City): _________________________________
Name of Airport/Train Station (departing from): ____________________________________

Return Date: __________________________ Preferred Return Time: _______________
Returning to (City): ____________________________________
Name of Airport/Train Station (returning to): _____________________________________
Is there personal travel included in this trip? ___________
If yes, please give the dates of the personal travel: _____________________________________
Complete and return to Tracey Wilkerson at tracey.wilkerson@cfpb.gov.
To be completed by Admin personnel:
Auth. Submitted ______________
Auth. Approved ______________
Itinerary sent to Traveler ______________
Notes:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

OMB Control Number: 3170-XXXX
Expiration Date: XX/XX/XXXX
______________________________________________________________________________
______________________________________________________________________________
Privacy Act Statement
The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB) to make travel
arrangements regarding your appointment as an advisory board member, panel, committee, or other group
membership, or for employment for the United States Government. The information will be used by and disclosed to
employees, contractors, agents and others authorized by the CFPB to receive this information to assist in related
activities. The information may also be disclosed in accordance with the routine uses outlined in the General
Services Administration’s (GSA) published Privacy Act system of records notice, GSA/GOVT-4 – Contracted
Travel Services Program, July 6, 2009 [74 FR 26700].
The collection of this information is authorized by 31 U.S.C. 3511, 3512, and 3523; 5 U.S.C. Chapter 57; and
implementing Federal Travel Regulations (41 CFR Chapters 300-304).
You are not required to submit any identifying information. However, not doing so may prohibit travel arrangements
or reimbursement from being processed.
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The OMB control number for this
collection is 3170-XXXX. It expires on MM/DD/YYYY. The time required to complete this information collection is estimated
to average approximately 10 minutes per response, including the time for reviewing any instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation
to respond to this collection of information is voluntary. Comments regarding this collection of information, including the
estimated response time, suggestions for improving the usefulness of the information, or suggestions for reducing the burden to
respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office),
1700 G Street NW, Washington, DC 20552, or by email to CFPB_Public_PRA@cfpb.gov.
The Bureau will not disclose any personally identifiable information collected except to the extent that it is required to do so by
law and as provided in the Privacy Act Statement listed above. Additionally, the Bureau will treat the information collected
consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.