Name: ____ Mr. ____ Ms. _________________________________
Social Security # _________________________________________
Teaching Position
______________________________________________________
# of Years You Have Taught High School _________
High School Name
______________________________________________________
High School Address
______________________________________________________
Home Address
_______________________________________________________
Telephone: Day _______________________________
Evening _____________________________________
Fax __________________________
E-Mail Address __________________________________________

Subject(s) taught that include(s) insurance in the curriculum:
_____________________ __________________________________ ________________________________________________________

List highest degree received and institution
_______________________________________________________

Have you taken an insurance course for academic credit or received
insurance related training of any kind?
_______________________________________________________
If yes, please indicate your experience in the insurance industry.
_______________________________________________________

_______________________________________________________

Are you involved in project InVEST? Yes ___ No ___
How many years _______________
If yes, please enter the name of the school with your InVest program
____________________________ __________________________

LODGING: You will be assigned a roommate unless otherwise requested.
Do you smoke? Yes ___ No ___
A limited number of single rooms are available at your expense for $45/night.
Do you want a single room? Yes ___No ___
I will not need lodging.

In the space below, please tell us your goal(s) for attending the Institute, what
you hope to learn, and how you will apply to the classroom what you learn in
the Institute. If more space is needed, please attach an additional page.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Either fax to (804) 828-7554 or mail to:
Diane Beamer
VCU Insurance Studies Center
Box 844000
Richmond, VA 23284-4000
dfbeamer@vcu.edu

Upon acceptance into the Institute, a refundable deposit of $50 will be required to hold your place. Money is refunded to you at the beginning of the course.

You may apply to one university location of your choice.