New England 1752 Club
	ROBERT C. DWELLY SCHOLARSHIP
	Scholarship Application for Certified Insurance Counselor (CIC) Institute

Name of Applicant:

Name of Agency / Company:

Business Address:

Home Address:

Business Phone:   Home Phone:

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?

CIC SCHOLARSHIP CONDITIONS

1. One scholarship will be awarded annually.

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

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

4. The scholarship includes the cost of the CIC session.

5. The scholarship recipient 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 CIC designation.         I agree with these terms.

APPLICATION DEADLINE IS JUNE 1, 2008

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Updated 1-23-2008