New England 1752 Club
	EDWARD B. CAULKINS SCHOLARSHIP
	Scholarship Application for Certified Insurance Service Representative (CISR)

Scholarship eligibility criteria include:

1. Applicant does not presently hold the CISR designation; and
2. Applicant intends to pursue a career in insurance; and
3. Applicant has at least one year of experience in the insurance industry.

Name of Applicant:

Name of Agency / Company:

Business Address:

Home Address:

Business Phone:   Home Phone:

E-Mail Address: 

Recommended By:

                                            Name of employer or other insurance industry personnel

PREVIOUS INSURANCE EDUCATION: (Please list all previous insurance or business related courses.)

Are you a licensed broker?  Yes             No

Are you employed in the insurance industry?  Yes        No

Position / Duties in present employment:

Length of time employed in present position:

Other insurance experience:

What motivated you to seek this scholarship?

CISR SCHOLARSHIP CONDITIONS

1. Two scholarships will be awarded annually.

2. The scholarship recipient will be notified by phone or mail.

3. The scholarship recipients will be formally recognized at the September meeting of the N.E. 1752 Club.

4. The scholarship will pay for the cost of the CISR session.

5. The scholarship recipients will be required to submit a completed course application to the club treasurer who will forward same to MAIA with appropriate payment.

By completing this form, checking the box below and submitting it to the New England 1752 Club, I hereby attest that I have made a commitment to further my education and I fully intend to complete the series of courses leading to the CISR designation.       

I agree with these terms.

APPLICATION DEADLINE IS JUNE 1, 2008

---

CISR Scholarship 2008
Revised: February 01, 2008.