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PRESIDENT’S/CHAIRMAN’S AWARD

APPLICATION FOR CIC SCHOLARSHIP

Year earned 2010 – For use during 2011

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? ____________________________________________________

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What are your reasons for applying? ________________________________________________________

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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: ___________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Signature of Agency Principal _____________________________________________________________

Return this form via email or mail by May 1, 2011 for President’s Award and July 15, 2011 for Chairman’s Award to:

Shawn Denman

Safeco Insurance - Central Region

1600 N. Collins Boulevard

Richardson, TX 75080

shawn.denman@

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