TSLA - Texas Surplus Lines Association, Inc.

The National Alliance for Insurance Education & Research

2010 CIC/CISR Memorial Scholarships
Nomination/Application Form

If you would like to apply for or nominate someone for the Avrohm Wisenberg 2010 CIC/CISR Memorial Scholarships, please fill out the form below, completing all information as requested. Once done, click on the Submit button to send the application to TSLA. All applications must be submitted by 12:00 noon on September 08, 2010.

Thank You! 

1. I am applying for the:        CIC Scholarship
                                 CISR Scholarship

2. Applicant's Name:             
   Nominated By (if applicable): 
   Agency:                       
   Street Address:               
   City:                         
   State:                          Zip Code: 
   Phone Number:                 
   Fax Number:                   
   Email Address:                

3. Please write a brief description of work experience, commitment
   to professional advancement, and reasons why the applicant
   should be considered for the scholarship.
   

4. Has the applicant started the program to which he/she is
   applying for a scholarship?   Yes   No

5. Additional Questions or Comments:

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Texas Surplus Lines Association, Inc.
Jean Patterson, Executive Director

Great Hills Corporate Center
9020-I Capital of TX Hwy N., Suite 370
Austin, TX 78759		      Phone: 
Fax: 
Email: 		 (512)343-9058
(512)343-2896
jptsla@tsla.org

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