0929d Travel Information National Veterans Creative Arts Festi

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 35 minutes

TRAVEL INFORMATION
NATIONAL VETERANS CREATIVE ARTS FESTIVAL
DEADLINE:
*Note to Festival participants, staff and others:
from and to the
Monday,
(departure day).

staff will be providing complimentary ground transportation
and Wednesday,
(arrival days) and

on Monday,

NAME (Last, First, MI)

DAYTIME TELEPHONE
NUMBER (Include area code)

VA MEDICAL FACILITY NAME

VA MEDICAL FACILITY ADDRESS (Street, City, State and Zip Code)

CELL PHONE NUMBER
(Include area code)

VA MEDICAL FACILITY TELEPHONE NUMBER (Include area code)

MODE OF TRANSPORTATION
AIR

CAR

I NEED ASSISTANCE GETTING ON AND OFF THE AIRCRAFT
BECAUSE I:

BUS

AM VISUALLY IMPAIRED

YES

USE A WHEELCHAIR

ARRIVAL INFORMATION
DATE OF ARRIVAL

TIME

NUMBER OF PEOPLE TRAVELING TOGETHER

IS A STAFF PERSON ACCOMPANYING PARTICIPANT
(If Yes, name of staff person)

YES

NO

NAME OF AIRPORT OR BUS STATION AND CITY AND STATE ARRIVING INTO
FROM
FLIGHT/BUS NUMBER

AIRLINE

DEPARTURE INFORMATION
DEPARTING VIA
CAR
DATE OF DEPARTURE

TIME

FLIGHT/BUS NUMBER

BUS
AIRLINE

SUBMIT COMPLETED FORM NO LATER THAN
TO:
Stephanie Torian
Host Site Coordinator (05/Vol)
VA Sierra Nevada Health Care System
975 Kirman Avenue
Reno, NV 89502
Phone: (775) 328-1411 / Fax: (775) 337-2276
[email protected]

VA FORM
FEB 2014

0929d

NO
OTHER