Title: Event Request Form to Edit
Original CoS Document (slug): event-request-form-to-edit
Login Required to view? No
Attached File: Event_Payment_Request_Form_02062020_(fillable).pdf
This file must be submitted with the State Director's permission with at least 3 weeks notice of the need for remittance
Created: 2018-10-23 09:55:56
Updated: 2021-06-21 12:39:08
Published: 2018-10-23 09:56:39
Converted: 2025-04-14T19:32:42.452804509
1 of 2
Rev. 2/6/2020
EVENT PAYMENT REQUEST FORM
(Submit this completed form to payment@cosaction.com at least 21 days before payment is due)
State laws limit our ability to reimburse volunteers in some states. Please obtain approval for your event before
incurring any expenses and requesting reimbursement.
Event Information
Your Information: Name: ___________________________ State: ______________ Position: ________________
Email: ___________________________ Phone: ____________________ Date: ____________
My COSA State Director is: ________________________________________________________
☐
I discussed this event with my State Director, and he or she approves of this payment request.
Has this event been done before & approved in the past? ☐ Yes ☐ No. When? ____________
Event Name:
______________________________________________________________________________
Event Host:
______________________________________________________________________________
Event Description: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Event Details:
Event Date: _______________ City, State: _______________ Est. Attendance: __________
Total Cost: ________________ Have you requested a non-profit discount? ☐ Yes ☐ No
Check all goals
that apply:
☐
Recruit volunteers/leaders
☐
Lobby Day at State Capitol ☐ Respond to Opposition
☐
Educate public / seminar
☐
Meet with state legislators
☐
Conduct Simulated COS
☐
Host booth at event
☐
Collect petition signatures
☐
Other: ______________
Have you secured the necessary volunteer support for the event to be successful? ☐ Yes ☐ No
If you will be collecting petition signatures, what is your goal amount? ______________________
Will you be submitting a request for print materials to distribute at this event? ☐ Yes ☐ No
Print Media Order Form is available online at https://conventionofstates.com/printorders
Anticipated Non-
COS Dignitaries:
______________________________________________________________________________
Lobbying:
Will this event involve volunteers communicating with legislators or their staff? ☐ Yes ☐ No
Will volunteers collect petition signatures or ask citizens to contact legislators? ☐ Yes ☐ No
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Rev. 2/6/2020
Itemized Budget
Cost:
Item for Purchase:
$ _____________ ______________________________________________________________________________
$ _____________ ______________________________________________________________________________
$ _____________ ______________________________________________________________________________
$ _____________ ______________________________________________________________________________
$ _____________
______________________________________________________________________________
Payment Information
Type of Payment:
☐
Credit Card (preferred)
☐ Check
☐ Wire Transfer
☐
Other: ___________
Payment Contact:
Name: ___________________
Email: ___________________
Phone: _________________
Address:
______________________________________________________________________________
Payment Deadline
______________________________________________________________________________
Insurance Information
(If the event requires insurance, please complete this section and attach a copy of the event contract.)
Venue Name:
_________________________ Date Insurance Needed: ______________________________
Venue Address:
______________________________________________________________________________
Venue Contact:
Name: ___________________ Email: ___________________ Phone: _________________
Additional Information
(Please provide additional information that would be helpful for COSA to consider in approving this event)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
COSA Office Use Only
Date Received
_________________________
This request was submitted: ☐ On-Time ☐ Late
Date Approved
RD: _____________________ Legal: ___________________ Exec.: _________________
Date of Payment
_________________________
Date PEQ Rec’d:
_________________________