Application and Related Forms

OMB Control Number: 3170-0037
Expiration Date: XX/XX/20XX

Travel Information Form
Advisory Board and Councils Office
Traveler
First Name:
Last Name:

Trip Information
Departure Date:

Preferred Departure Tim e:

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

Return Date:

Preferred Return Ti me:

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 yo ur desktop and retur n t o
Crystal Dully with the Advisory Board and Councils Office at Crystal.Dull y@cf pb.gov.
Notes:

Privacy Act Statement
5 U.S.C. § 552a(e)(3)
The information you provide to the Consumer Financial Protection Bureau (“CFPB”) will be used to e nable travel service providers under
contract to the Federal Government to authorize, issue, and account for travel and travel reimburse ments provided to individuals on official
Federal Government business.
Information collected by the CFPB may be used by and disclosed to employees, contractors, agents, and others authorized by the CFPB to
receive this information to assist in related activities. It may also be disclosed:
•
to another Federal agency, Travel Management Center (TMC), online booking engine su ppliers and the airlines that are required to
support the DHS/TSA Secure Flight program;
•
to a Federal agency employee, expert, consultant, or contractor in performing a Federal duty for purposes of authorizing, arranging,
and/or claiming reimbursement for official travel, including, but not limited to, traveler p rofile information;
•
to a travel services provider for billing and refund purposes; and
•
pursuant to the government-wide published Privacy Act system of records notice, GSA/G OVT-4 Contracted Travel Services Program,
41 FR26700.
The collection of this information is authorized by Public Law 97-258, 101-576, 97-258, codified at 3 1 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 or provide any identifying information; however, if you choose not to pr ovide the informati on, the CFPB may not
be able to provide travel services.

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 MM/DD/YYYY. The time required to complete this information collection is estimated to average
approximately 10 minutes per response, including the time for reviewing any instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to
respond to this collection of information is voluntary. 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 CFPB_PRA@cfpb.gov.
The Bureau will not disclose any personally identifiable information collected except to the extent that it is required to do so by
law and as provided in the Privacy Act Statement listed below. Additionally, the Bureau will treat the information collected
consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.