Request Funds for CE Event

Regional Representatives may use the form below to request funds for approved CE events. Completion of Request Form does not guarantee funds. Please contact GCCA Treasurer, Amy Laughter, with any questions you may have. You may also chose to download a hard copy and mail to the treasurer.

Regional CE Event Budget Request

This form is to be used by regional representatives ONLY in order to request honorarium or reimbursement for GCCA sponsored CE events.

Title of CE Event*
Region Requesting Funds (i.e. Midwest)*
Name of Representative*
Email Address*
CE Approval from CE Chair*
- Yes, program has been approved
- No, I have submitted the program but have not yet received approval
- No, I have not yet submitted the program
Please Choose Which of the Following Options You Are Requesting Funds For*
- Honorarium (this is to be used when paying a presenter for the time, travel costs, etc).
- Reimbursement (this is to be used when receiving reimbursement for supplies for event)
Name of Individual Receiving Funds*
(If this is for reimbursement, put your name. If this is for honorarium, put the presenters name.)
Date of Service Rendered
MM slash DD slash YYYY
Amount to be Paid*
Please enter a number less than or equal to 200.
Please Attatch Completed Flyer for CE event*
Max. file size: 256 MB.
Please Attach Copies of Receipts for Reimbursement
Drop files here or
Max. file size: 256 MB.
Name
This field is for validation purposes and should be left unchanged.