39
!!!
! ! ! VSCA SCHOLARSHIP APP!LICATION COVER PAGE ________________________________________________________________________
!APPLICANT ________________________________________________________________________
C!URRENT ADDRESS ________________________________________________________________________
C!ITY, STATE, ZIP ________________________________________________________________________
C!OLLEGE OR UNIVERSITY SELECTED /STATE ________________________________________________________________________
!UPCOMING YEAR – EG: JUNIOR, GRADUATE MAJOR OR AREA OF STUDIES “ATTACH CURRENT PHOTO” !!!!!!!!!!
!CERTIFICATION OF PARENT’S ELIGIBILITY FOR! VSCA SCHOLARSHIP ______________________________________________________
P!ARENT ____________________________________________________
!APPLICANTS NAME AND RELATIONSHIP ________________________________________________________________________
I!NSURANCE AFFILIATION (EG:, ADJUSTER, APPRAISER) ________________________________________________________________________
J!OB TITLE / DESCRIPTION /EMPLOYER ________________________________________________________________________
L!OCAL CLAIMS ASSOCIATION - MEMBERSHIP YEARS This is to certify that the above named person has been a member, in good standing, of the
_______________________________ Claims Association for the 2 previous calendar years. The member’s local
dues for this year are current and our Association is responsible to pay this Member’s State Dues.
________________________________________________________
!State Director (or Treasurer if Director is parent of Applicant) !Date_____________________