To view this on the COS website, click here [[https://conventionofstates.com/files/event-request-form-to-edit|event-request-form-to-edit]]

To download the pdf file from the COS website, click here [[https://conventionofstates.com/files/event-request-form-to-edit/download|Event_Payment_Request_Form_02062020_(fillable).pdf]]


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====== Event Request Form to Edit ======


This file must be submitted with the State Director's permission with at least 3 weeks notice of the need for remittance.

Attachment: 2309/Event_Payment_Request_Form_02062020_(fillable).pdf
| \\ \\ \\ \\ {{:public:cb_mirror:files_7255_pdfto001.png?nolink&918x1188|}}\\ \\ 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 \\ \\ \\ \\ {{:public:cb_mirror:files_7255_pdfto002.png?nolink&918x1188|}}\\ \\  \\ \\  \\ \\ 2 of 2\\ \\  \\ \\ // //\\ \\  \\ \\ 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: \\ \\  \\ \\ %%__%%%%__%%%%__%%%%__%%%%__%%%%__%%%%__%%%%__%%%%__%%%%__%%%%__%%%%__%%_   \\ \\  \\ \\ |
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|  __Page Metadata__  ||
|Login Required to view?  |No                  |
|Created:                 |2018-10-23 13:55 GMT|
|Updated:                 |2021-06-21 16:39 GMT|
|Published:               |2018-10-23 13:56 GMT|
|Converted:               |2025-11-11 12:12 GMT|
|Change Author:           |Joanne Laufenberg   |
|Credit Author:           |                    |