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PRESIDENT’S/CHAIRMAN’S AWARD

APPLICATION FOR CIC SCHOLARSHIP

Year earned 2011 – For use during 2012

Please check the appropriate box: □ President’s Award Winner □ Chairman’s Award Winner

Name of Applicant: ___________________________________________________________________

Name of Agency: ___________________________________________________________________

Business Address: ___________________________________________________________________

___________________________________________________________________

Business Phone: __________________

Agency Code: __________________

Are you a licensed agent? ___________ Will insurance be your principle means of income? _____________

Have you attended a previous CIC institute? __________________________________________________

How long have you been employed at current agency? __________________________________________

What is your agency position? _____________________________________________________________

Do you have other insurance experience? ____________________________________________________

_____________________________________________________________________________________

What are your reasons for applying? ________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

How many CICs are there currently in your agency? __________________________________________

SUPERVISORS MUST COMPLETE THE FOLLOWING:

Do you feel the applicant will have the time and commitment to complete all five parts? ________________

Do you feel the applicant will have the experience necessary to successfully complete all parts? ___________

Please tell us why you are recommending this person: ___________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Signature of Agency Principal _____________________________________________________________

Return this form via email or mail by May 1, 2012 to:

Thomas Dormer

Safeco Insurance - Mountain Region

14123 Denver West Parkway

Golden, CO 80401

thomas.dormer@

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