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