2017

SCHOLARSHIP APPLICATION

HARRY HOUSE CAPTIVE INSURANCE SCHOLARSHIP

Students applying for this scholarship must:

* be currently enrolled in a risk management program at an accredited college or university; and

* be of a minority status -- For the purposes of this scholarship, minority is defined as having membership in a racial or ethnic minority group historically disadvantaged within the context of the United States. The most common members of these groups are Black/African American students, Hispanic/Latino/Chicano students, Asian students and Native American/American Indian/Eskimo students.

NAME:

Last First

GENDER: DATE OF BIRTH:

PHONE: E-MAIL:

LOCAL ADDRESS:

HOME ADDRESS:

COLLEGE OR UNIVERSITY:

MAJOR:

Please complete:

· Total credit hours earned to date: __________

· Credit hours enrolled in: Fall 2016 semester: __________ Spring 2017 semester: _________

· Anticipated credit hours enrolled in Fall 2017 semester: __________ Full time____ Part time____

· Student status Fall 2017 semester: Freshman___ Sophomore___ Junior___ Senior___ Grad Student___

· Current grade point average: __________

· Expected graduation date: __________

QUALIFYING MINORITY BACKGROUND:_________________________________________________

How did you learn about the Harry House Scholarship?:

1. List campus or community activities you have been involved in, explaining your role in the organization.

Also, list any leadership positions you have held (if necessary, submit an additional page).

2. Please state briefly why you are interested in ICCIE. How does this opportunity relate to your long-term

goals?


ICCIE requests your signature below verifying that the information provided on the application is truthful and accurate to the best of your knowledge.

This form must be submitted along with TWO LETTERS OF REFERENCE (preferably from faculty or current/former employers).

The scholarship recipient will be announced on Wednesday, August 9th during the general session at the Vermont Captive Insurance Association (VCIA) annual conference in Burlington, VT.

· Are you planning to attend the 2017 VCIA Conference in August? Yes No Don’t Know

PLEASE SUBMIT ALL MATERIALS BY JUNE 30, 2017

VIA MAIL TO:

ICCIE

Harry House Captive Insurance Scholarship

2517 Shelburne Rd, Suite #2

Shelburne, VT 05482

Or VIA FAX TO:

ICCIE

802-651-6851

Or VIA EMAIL (as word doc. or PDF) TO:

_____________________________________ ________________

Student’s Signature Date

For questions, call ICCIE at 866-60-ICCIE (42243) or email Angela Gale at .

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