Application and Related Forms

OMB No: 3170-0037
Expiration: XX/XX/XXXX

Travel Information Form Advisory
Board and Councils Office
Traveler

First Name:
Last Name:

Trip Information
Departure Date:

Preferred Departure Time:

Time Zone

Departing from (City):
Name of Airport/Train Station (departing from):
Return Date:

Preferred Return Time:

Time Zone

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:
Once you have completed the form please save the document to your desktop and return to
Kimberly Trezvant with the Advisory Board and Councils Office at Kimberly.Trezvant@cfpb.gov.
Notes:

Privacy Act Statement 5 U.S.C. 552a(e)(3)
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 CFPB will collect your name and itinerary information, including arrival and departure locations, times, and methods of
transportation. Information collected will be treated in accordance with the General Services Administration’s (GSA) published Privacy Act
System of Records Notice (SORN), GSA/GOVT-4 – Contracted Travel Services Program, 74 FR 26700. 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 described in the SORN. 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 3170-0037. It expires
on 07/31/2016. The time required to complete this information collection is estimated to average approximately 10 minutes per response. .
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 PRA_Comments@cfpb.gov.