1999
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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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