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Date :

/___

Local Conveyance
Claim
Visited Place:
__________________________________ Date_______________
Distance in Kms (from office):
Purpose:
_____________________________________________________________
a) Mode of Conveyance: Two Wheeler/Car/Auto Charge (tick, which is applicable)
b) Incase of, Two wheeler & Car, please furnish the below details:
Starting Km: _________
Ending Km:
_________
Total Kms run: _________
Eligible Reimbursement per Km Rs.____ Total Reimbursement Rs._______
c) Incase of Auto: Charges incurred _______________________________
Prepared By:
Approved By:
Name:
Department:

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