Form OSM 105 OSM 105 Nomination and Request for Payment Form for OSMRE Techni

UNITED STATES DEPARTMENT OF THE INTERIOR
Office of Surface Mining Reclamation and Enforcement
NOMINATION and REQUEST FOR PAYMENT FORM for
OSMRE TECHNICAL TRAINING COURSES
OMB 1029-0120
Expiration Date: 07/31/2019

PART I: NOMINATION FORM
1. Course Title:

2. Date:

3. Location:

4. Nominee’s Name: (Last, First, Middle Name)

5. Nominee’s Title:

6. Nominee’s Work Phone No.:

7. New Traveler:

8. Nominee’s E-mail Address:

9. Program:

Yes
No
Title IV - AML
Title V - Regulatory

10. Name of Agency:

11. Official Duty Station: (Complete Overnight
mailing Address)

12. Residence: (City and State)

Miles to training site:

Miles to training site:

13. Supervisor’s Name:

14. Supervisor’s E-mail Address:

15. Supervisor’s Mailing Address:

16. Supervisor’s Telephone Number:

Please provide your State Training Contact's Name: _____________________________________________
PAPERWORK REDUCTION ACT STATEMENT
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control
number. This information is being collected to calculate the type and number of classes and instructors needed to complete
OSM’s technical training mission, and to estimate costs for our annual budget. We do not use the information for any other
internal secondary purpose.
Public reporting burden for this form is estimated to average 5 minutes per response, including the time for reviewing the
instructions, gathering and maintaining data, and completing and reviewing the form. Response is required to obtain a benefit.
Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer,
OSM, Room 202 SIB, 1951 Constitution Ave, NW, Washington, DC 20240.
OSM Form 105
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PART II : REQUEST FOR REIMBURSEMENT OF TRAVEL AND PER DIEM EXPENSES
(Please note: Only complete this part if you are seeking reimbursement)

17. Requested Mode of Travel:

Government-owned Vehicle

Common Carrier (air)

Privately Owned Vehicle

Other (specify)

Rental Car

IF PRIVATELY OWNED VEHICLE (POV) IS CHECKED ABOVE, PLEASE CHECK ONE OF THE FOLLOWING.
THIS WILL DETERMINE THE MILEAGE RATE FOR POV USAGE.

Individual has no access to a government vehicle
Government vehicle available in pool and individual chooses to use POV
Government vehicle assigned to individual and individual chooses to use POV
Closest major airport & miles to/from Residence:
One Way:
Closest major airport & miles to/from Office:
One Way:
18. Per Diem Requested For:

Lodging

Beginning Date:

Ending Date:

Meals and Incidentals
19. Fund Request:
We do not have funds available to pay travel and per diem expenses for the above nominees because:
Sufficient funds were not made available through legislature’s appropriation process.
As a practice, the State does not provide out-of-state travel authority for the purpose identified above.
Letter attached.
Other (please explain briefly):

Please note: Nominations will be accepted only if they are submitted by the Training Contact in
your State, Tribal, or OSMRE office. Additionally, to be accepted, nomination must be signed by
your supervisor.

Authorized Signature

OSM Form 105
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