Jan 15, 2013 - Phone Number. E-mail address. Graduation Date or GED Date. If returning to college after a break in attendance, college attended. Work ...
WESTFIELD INSURANCE AND WESTFIELD AGENTS ASSOCIATION SCHOLARSHIP PROGRAM FORM I - APPLICATION
Dependent of agency employee APPLICANT DATA
Dependent of Westfield Group employee
Last Name
First
Middle Initial
Address
Apt. # State
City
Zip Code
Phone Number
E-mail address all communication will be directed to this email address
Date of Birth
High School Name
Graduation Date
or GED Date
If returning to college after a break in attendance, college attended PARENT or LEGAL GUARDIAN INFORMATION
Last Name
First
Middle Initial Apt. #
Address State
City
Zip Code
Work Location/ Agency Name & Location Westfield assigned agency #
E-mail address All communications about the application will be directed to the student's email address. Parent or legal guardian email address will be carbon copied (cc) when student is contacted
Work Title Work Phone Relationship to Applicant I do not have 10% or more ownership interests in any independent insurance agency partnering with Westfield Insurance. I am not a Westfield leader level 3 or above. COLLEGE DATA
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Name of college or university you plan to attend. (If unknown, please list in order of preference the schools to which applications for admission have been sent.) City
State
City
State
City
State
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WESTFIELD INSURANCE AND WESTFIELD AGENTS ASSOCIATION SCHOLARSHIP PROGRAM FORM I - APPLICATION (continued) WORK EXPERIENCE
ACTIVITIES, AWARDS AND HONORS
School - (student government, music, sports, etc.) Community - activities without pay (civic, volunteer, etc.) Awards/Honors list any received. Attach additional sheets if necessary
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Describe your paid work experience. Indicate dates of employment in each job and number of hours worked per week. Company/Position
Type of activity
Dates From- Mo./Yr. To- Mo./Yr.
Hours per Week
Name of activity, honor or award
Years involved Fr.
So.
Jr.
Sr.
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UNUSUAL
CIRCUMSTANCES
Please report any unusual family or personal circumstances, if applicable, that have affected your academic achievement in school, work experience or your participation in school and community activities.
CERTIFICATION In submitting the application, I certify that the information provided is complete and accurate to the best of my knowledge. Falsification of information may result in termination of any scholarship granted. This application becomes property of Westfield Insurance and the Westfield Agents Association.
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WESTFIELD INSURANCE AND WESTFIELD AGENTS ASSOCIATION SCHOLARSHIP PROGRAM FORM I - APPLICATION (continued) ESSAY
Please write a 500-600 word essay as outlined in the Scholarship Policy. Describe your greatest influence (person or event) and how it will shape your future.
Applicant name Parent/legal guardian name
Parent work location/ Agency name & location
SUBMISSION
Return to Westfield with required essay, postmarked by January 15, 2013: Westfield Insurance - Attn: Community Investment - PO Box 5001 - Westfield Center, OH 44251-5001
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