EMPLOYEE RELOCATION: REIMBURSEMENT REQUEST FOR FACULTY
SECTION I: TO BE COMPLETED BY FACULTY MEMBER
NAME ________________________________________
APPOINTMENT DATE ___________________
RUTGERS EMPLOYEE ID ____________________
DEPARTMENT _____________________________________________
SCHOOL __________________________________________
CAMPUS
___________________________
ACADEMIC AND ADMINISTRATIVE TITLES _____________________________________________________________
MOVING FROM ______________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
MOVING TO ________________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
TOTAL MILEAGE ONE WAY ________________
COMMERCIAL VENDOR USED ________________________________________
OTHER MOVING EXPENSES (list):
AMT:
$ ___________
$___________ ________________________
$___________ ________________________
$___________ ________________________
TOTAL REIMBURSEMENT REQUESTED:
$__________________ (Attach all original receipts.)
It is understood that I will comply with the Rutgers University (“University”) Employee Relocation Policy (Section 60.1.6).
This agreement is not a contract for employment or appointment, nor a guarantee, if employed, of continued employment for a
specific period. It is further understood that the University will be held harmless for any loss or damage to property or injury to
any individual that may occur as a result of the relocation.
______________________________________________________
Faculty Signature
Date
SECTION II: APPROVALS
ACADEMIC BASE SALARY: $______________________
REIMBURSEMENT APPROVED: $ __________________
DEPARTMENT CHAIR: ______________________________________
INDEX NUMBER: ____________________
PRINT NAME: ______________________________________________
DATE: ______________________________
RUTGERS INTER-OFFICE ADDRESS: ____________________________________________________________________
BUDGET/GRANT: ___________________________________________
DATE: ________________
DEAN: _____________________________________________________
DATE: ________________
VICE CHANCELLOR FOR ACADEMIC AFFAIRS: ___________________________________ __ DATE: ______________
Rutgers Employee Relocation Policy Form (Section 60.1.6)
Form Revised July 2013