| Ethics Commission, North Dakota

Official’s First Name

Official’s Last Name

Official’s Position with the State

Destination Visited

Travel Start Date

Travel End Date

Purpose of Travel

Source(s) of Expenses Paid (include for lodging and meals)

Estimated or Actual Amount Spent for Expenses (include lodging and meals)

Number of Any Accompanying Family Members (if any)

Expenses Paid Categories (check all that apply):

Air Transportation

Ground Transportation

Lodging

Meals

Entertainment

Other Activities

Describe

I certify the information provided in this travel disclosure form is true, correct, complete, and of my own personal knowledge. I further certify I am the public official named or the public official’s authorized representative and will fully cooperate in the process regarding the filing of this travel disclosure form.

Signature (typed name is acceptable)

Signature Digital

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