Scholarship Group Form

1. Credit Union / Chapter

2. Total # of Participants

3. Asset size of CU

OR Participating CUs with less that $5M in assests

4. Contact Person

Phone Number

Address

City, State, Zip

E-mail

5. Type of Scholarship (select one)

ICU System Training (Cluster Training, League Personalized Session)

Certification Course (CCUE)

Self Study Course (STAR / VAP / VLP / MERIT)

Other

Specify Other:

6. Dollar Amount Requested

7. Topic of Course & Date of Program

8. Detail Cost of Program Below (specify registration fees, transportation & lodging, materials, etc.):

9. Will participants use personal time while receiving this training?

Yes

No

10. Will chapter or credit union help pay tuition/expenses?

Yes

No

If yes, how much (%) is covered?

11. Have you ever applied for an ICU Foundation Scholarship?

Yes

No

Received one?

Yes

No

12. Explain how will this educational program will benefit your credit union(s):

13. Indicate extenuating circumstances relevant to this application:

14. List the participants, their credit union affiliation and indicate staff of volunteer:

Please see website or printable application form for details regarding scholarship eligibility requirements.