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CIPT Application

Candidate Information

Full Name

Address *

City *

State *

Postal code *

Phone *

Email *

Employer *

Local Asociation *

Program Requirements

Completion date of first core subject course: *

Completion date of final core subject course: *

If completed under a name other than your present name, please indicate such name:

Evidence of completion for CIPT courses does not have to accompany the application. All information will be verified using course records maintained at FIWT headquarters. You will be notified if there are any discrepancies.

2) Continuous FIWT membership through the following local association: *

If a portion of your membership was filed under a name other than your present name, please indicate such name:

Evidence of qualifying membership will be verified by records maintained at FIWT headquarters. You will be notified if there are any discrepancies.

Business Courtesy

Would you like a letter acknowledging your accomplishment sent to your employer from the State FIWT President?

Yes

No

If yes, please provide name and address for mailing

I hereby certify that the information provided on this application is true and correct.

Signature *

Clear

Date *

Collect Payment *

$ 25

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Federation of Insurance Women of Texas

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