Center for Civic Engagement and Leadership
ATTENTION: Before completing this application, you must review the Student Mileage Reimbursment Instructions.
STUDENT INFORMATION:
Name:
ID Number: Class Year: CMR:
Phone: E-mail :
COURSE INFORMATION:
Semester: Fall Spring
Year:
Course:
Professor:
PLACEMENT INFORMATION:
Placement Agency: Placement Agency Street Address: Placement Agency City: Scheduled Time: Scheduled Day: Scheduled Time of Day:
MILEAGE INFORMATION:
Total Number of Visits/Trips for Semester:
Total Number of Miles-Round Trip (SLU to Agency + Agency to SLU):
Total Number of Miles for Semester:
Total Amount Requesting (Total number of miles x $0.55 =
ADDITIONAL COMMENTS:
Please use this section to give additional information or special circumstances as to why you need to drive to your placement:
