CPDM Scholarship Application
PURPOSE: The purpose of the scholarship is to provide the opportunity to obtain CPDM certification to those industry professionals who might otherwise not have financial resources or means to obtain CPDM certification. The applicant must be currently (or within the past 12 months) employed within the field of Absence Management and must not have received this scholarship in the past.

*The CPDM Scholarship, valued at $549 per course, is granted through the partnership between Disability Management Employer Coalition (DMEC) and the Insurance Educational Association (IEA).

**The Fall CPDM Scholarship will be randomly awarded to the winner from among the qualifying applications that are submitted by Septembere 1st 2017. The winner will be notified by September 7th, 2017.

Certified Professional In Disability Management
Name & Title
First Name *
Your answer
Last Name *
Your answer
Employer (or last employer) *
Your answer
Currently employed at employer stated above *
Date you left most recent employer
MM
/
DD
/
YYYY
Title (or most recent title if unemployed) *
Your answer
Contact Info
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
E-Mail Address *
Your answer
Preferred Phone No. *
Your answer
Type of phone *
Alternative Phone
Your answer
Type of phone
Professional Background
Brief employment History *
Please include current or most recent job description
Your answer
Please list any certifications, licenses, degrees or accreditation you may currently hold.
Your answer
Reason for Scholarship Request
Does your employer offer education assistance? *
Please note, if your employer offers assistance but you are unable to use it for this particular course, you must indicate yes. Please note, we may seek verification from your employer.
Have you received a CPDM Scholarship previously? *
Are you currently a member of DMEC *
Please describe why you are applying for this scholorship *
You have already confirmed that your employer can not pay for this program. Please let us know additional reasons why you can not pay for this on your own.
Your answer
Why are you pursuing this designation and what do you believe it will mean for your career? *
Your answer
Please confirm you would like to receive our news letters and e-blasts on upcoming education and development opportunities. *
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