Southern 1752 Club Scholarship Application  
 
Please complete the information below to be considered for our scholarship program.  Please note that the scholarship is available to individuals employed in an agency and is only for recognized insurance educational programs.  Such programs can include, but are not limited to, CPCU, CIC, CISR, etc. 

The scholarship(s) are awarded in April and October every year, based on a vote of the members present.  Upon awarding a scholarship, the club will require that documentation be provided before payment is made.  Documentation required will include evidence that the course was paid for, completed, and the appropriate exam passed.

Scholarship winners will be contacted after each meeting to arrange for the presentation of documentation to the club Treasurer.

 

Date (mm/dd/yyyy)  
Name  
Agency Name  
Years Employed  
Current Position  
Business Address  
City  
State  
Zip  
Email Address  
Phone    
Insurance Experience    
Insurance Agency Employment  
or    
Insurance Company Employment  
     
Will your employer reimburse you for tuition if you do not receive this scholarship? (y/n)  
Will your employer reimburse you for travel and other expenses related to your study?( y/n)  
List 3 companies represented by your agency:  
   
   

The reasons I feel I deserve to receive this scholarship are:

 

My future plans in the insurance industry are:

 

My intended course of instruction for this scholarship would be for (CPCU, CIC, CISR, etc):

 

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