Your First & Last Name (required)

    Your Email Address (required)

    Your Phone Number (required)

    Your Mailing Address, City, State, Zip

    Credit Union Name (required)

    Credit Union Mailing Address, City, State, Zip (required)

    Asset Size (required)
    Under $50 millionOver $50 million

    Credit Union Yearly Dues Paid (required)
    YesNoWaived (asset size under $50 million)

    Type of Request
    Registration scholarship onlyHotel room scholarship onlyBoth registration and hotel scholarship

    If Hotel Room Scholarship is requested, please specify your arrival date and number of nights