Request for Admission
Application Fee Waiver
SEND THIS FORM DIRECTLY TO THE POSTSECONDARY
INSTITUTION/ORGANIZATION
TO: DEAN/DIRECTOR OF ADMISSION AT
NAME OF COLLEGE OR UNIVERSITY
CERTIFICATION STATEMENT: I certify that I understand and meet all eligibility requirements to request an admission application fee waiver.
STUDENT’S NAME STUDENT’S SIGNATURE
STUDENT’S ADDRESS CITY STATE ZIP
STUDENT: Print or type the information requested below. You must personally sign the Certication Statement.
AUTHORIZED OFFICIAL'S NAME AUTHORIZED OFFICIAL'S SIGNATURE
AUTHORIZED OFFICIAL'S TITLE AUTHORIZED OFFICIAL'S EMAIL
NAME OF SECONDARY EDUCATIONAL INSTITUTION OR ORGANIZATION CEEB# OR PROGRAM#
ADDRESS PHONE
AUTHORIZED OFFICIAL: Print or type the information requested below and check the indicator(s) of economic need. You must personally sign
the Certication Statement.
CERTIFICATION STATEMENT: I certify that the student named on this form is either (a) currently enrolled in the 11th or 12th grade at this school,
or if not currently enrolled, (b) an individual who is seeking enrollment as an undergraduate to an institution of postsecondary education; AND meets
the indicator(s) of economic need checked below.
Student has received or is eligible to receive an ACT or SAT testing fee waiver.
Student is enrolled in or eligible to participate in the Federal Free or Reduced Price Lunch program (FRPL).
Student’s annual family income falls within the income Eligibility Guidelines* set by the USDA Food and
Nutrition Service.
Student is enrolled in a federal, state or local program that aids students from low-income families
(e.g.,TRIO programs such as Upward Bound).
Student’s family receives public assistance.
Student lives in federally subsidized public housing, a foster home, or is homeless.
Student is a ward of the state or an orphan.
Other request from high school principal, high school counselor, nancial aid ofcer, community advisor/leader
or other ofcial who can attest to the student's circumstances.
Given my knowledge of this student’s family circumstances and after reviewing the eligibility guidelines, I
believe that providing the application fee would present a hardship. Explanation:
ECONOMIC NEED: The student must meet at least one of the following indicators of economic need. If no item is checked, the request will
be denied.
*To view USDA Income Eligibility Guidelines for the Free or Reduced Price Lunch Program or review FAQs related to this form visit
http://bit.ly/NACACfeewaiver.
