Application for CoDA Service Conference (CSC) Travel Reimbursement Opportunity (TRO)

for Delegates of Voting Entities (VE)
Thank you for taking the time to fill in this application. There are several questions that you may want to consider before you submit the form. We suggest that you consider printing this form and review the information asked for before you submit the form. (A red * denotes a required field.)
This application form applies to CoDA's Service Conference only.

Personal Information

Last name*

First name*

Street Address*

Street Address 2

City*

State

Zip

Country*

email address*

Phone # (with area code = country code)*
If you don't have a phone, enter "none".

Name of Voting Entity*
(if you do not have a organized service structure as a Voting Entity, your state or country is the VE)

Voting Entity (VE) Information

VE address 1

VE Address 2

VE City

VE State

VE Zip

VE Country

VE Email

VE Website

VE Phone

Application Questions

Were you elected by your voting entity as a delegate?*

Yes No

Documentation of appointment by your fellowship groups.
Provide minutes from your VE showing that you were elected/appointed by the VE, or minutes from meetings in the area you plan to represent. In lieu of minutes, provide contact information for meetings that have approved you to represent them at the CoDA Service Conference.

Have you personally received a TRO?*

Yes No

If "Yes", when and for what VE?

Briefly describe what you understand your role as Delegate at the CoDA Service Conference.*

Has your VE sent Delegates to the CoDA Service Conference in the past?*

I don't know Yes No

If known, what years did your VE send delegates to CSC?

Has any delegate from your VE received a TRO to attend CSC?*

Yes No I don't know

If "Yes", when?

Signature*
By typing in your name and submitting this form you are
1) acknowledging you have read the accompanying Instructions and Policy (Link: http://coda.org/default/assets/File/2016_TROinstruction%20policy.pdf ), and
2) reporting that your information is accurate and truthful to the best of your knowledge.

Send me a copy of my responses

Email address

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