Employee Waiver Form
(Application and Certification for Exemption from Payment of Tuition and Fees)
Name of Student: _______________________________________________
Student ID or
Social Security Number: ________________________________________________
Street Address: ________________________________________________
City, State, Zip: ________________________________________________
Attending: ____________________________________ Community College
Certificate of Employee
Employee Name: ________________________________________________
Street Address: ________________________________________________
City, State, Zip: ________________________________________________
Type of Waiver (check one) Semester Year
Employee: _________ Fall __________
Spouse: _________ Spring __________
Dependent Child _________ Other __________
This is to certify that the information submitted on this application is complete and accurate. If
the waiver application is for a spouse or dependent child, I hereby attest that the above named
student is my spouse or dependent child.
__________________________________________ __________________
Signature of Employee Date
Certificate of Employer
This is to certify that the above named employee is employed by the Board of Trustees of
Community Colleges/Northwestern Connecticut Community College, and is eligible to receive a
waiver of tuition and fees, as requested in this application, pursuant to Board policy and/or
pursuant to an applicable collective bargaining agreement.
______________________________________________ ___________________
Name: Date
Title:
Note: The Board reserves the right to require submission of tax returns to substantiate claimed
spousal or dependent child status. False reporting may be cause for disciplinary action.
NORTHWESTERN CONNECTICUT COMMUNITY COLLEGE
