Marketing CoOp Request
Date Requested
*
-
Month
-
Day
Year
Date
Agent Name
*
First Name
Last Name
Agency Name (if applicable)
Payee Name (PLEASE MAKE SURE TO VERIFY WHO THE PAYMENT SHOULD BE MADE TO)
*
Agent or Agency whom Co-Op should be payable to
Agent Email
*
example@example.com
Requested By
*
First Name
Last Name
Garity Staff Requested By Email
*
example@garityadvantage.com
CC Email - if needed
example@example.com
Carrier
*
Marketing Total Spend
*
CoOp Amount Already Paid?
*
Yes
No
Full or Partial Payment
*
Full
Partial
How was Payment Made?
*
Who's Credit Card was Used?
Amount Paid
Dollar Amount
Amount to be Reimbursed
*
Type of Marketing
Type of Marketing
Billboards
Community Meetings
Exhibiting/Sponsoring Materials
Leads
Mailings
Print Advertising
TV/Radio
Web/SEO/Social Media
Other
Receipt Order Ref
*
Upload Receipt/s
Browse Files
Cancel
of
Notes
Notes only Required if Co-op Amount is Over $5000.00
Submit Request
FOR VP USE ONLY:
APPROVED
NOT APPROVED
VP Review Date:
-
Month
-
Day
Year
Date
REVIEWED BY:
Reason NOT Approved:
FOR CFO USE ONLY:
PAID DATE:
-
Month
-
Day
Year
Date
PAID VIA:
DIRECT DEPOSIT
CHECK
CREDIT CARD
Should be Empty: