Request for Admission Application
Fee Waiver
SEND TH IS FORM DIRECT
LY
TO THE P
OS
TS ECONDARY INSTITUT ION/OR
GA
NI
ZAT
ION
....
Nationa l Assoc i at i on f or
College
Adm
i ssi
on
Coun s
el
i ng
Cwdin
g 1
hc
u
'<>y
10 l
lig
her
<
oi
iOca
,.
on
TO: DEAN/DIRECTOR OF ADMI
SSION
AT
-------~~~~~==~:-=:=:-:--------------------
N
AME
OF
CO
LLE
GE
OR
UNIVERSI
TY
STUDENT:
Pn
nt or type the
mfo
rm
at
1on
re
quested below
Yo
u must personally
s1gn
the
Ce
rtifi
ca
tion S
ta
teme nt
C E RT I F
ICATIO
N ST A
TE
M
EN
T : I certify that I understand and meet all eligibility requirements to
requ
est
an
admission application fee waiver.
STU
DE
NTS
NA
ME
STU
DE
NTS
SIGN
ATU
RE
STU
DE
NTS
AD
DRE
SS
CITY STATE
ZP
AUT
H
OR
I
ZED
OFF
IC I
AL
Pn
nt or type t he
mfo
rm
at
1on
req
uested below. and check t
he
1nd1
ca
tor(s) of econom1c
nee
d
Yo
u
must
personally s1
gn
he Cer
1ficat
1on
S
ta
teme nt
C E RT I F
ICATIO
N ST A
TE
M
EN
T : I certify that
the
student named
on
this
form
is currently enrolled
in
the
11th
or
1tt'
grade at this school and meets
the
indicator(s) of economic need checked
below.
AU
T
HO
RIZED OFFICI
AL
'S
NAM
E
AU
T
HO
RIZED OFFICIAL'S SIGNATU
RE
AU
T
HO
RIZED
OFF
ICI
AL
'S T
rrL
E
AU
T
HO
RIZED OFFICIAL'S
EMA
L
NAME
OF SE
CO
N
DARY
E
DUCA
TION
AL
IN
STI
TUTION
OR OR
GANIZATI
ON
C
EEB#
OR
PR
OGRAM #
AD
DRE
SS
P
HO
NE
ECONOM
IC
NEED
The
st
ude
nt must meet at least one of the followmg
md
1cators of econ
om
1c need If no 1tem IS
checke
d.
t
he
request w1
11
be
de
m
ed
0 Student has recei ved or is eligible to recei ve an ACT or SAT testing fee waiver.
0 Student is enrolled in or eligible to participate in the Federal Free or Reduced Price
Lunch program (FRPL).
0 Student's annual family income falls
wi
thin the income Eligibi
li
ty Guidelines• set by
the USDA Food and
Nu
trition Serv ice .
0 Student is enrolled in a federal, state or local program that aids students from low
income families (e.g., TRIO programs such as Upwa
rd
Bound).
-
0 Student's family receives public assistance .
0 Student lives in federally subsidized public housing , a foster home or is homeless.
0 Student is a ward of the state or an orphan.
0 Other request from high school prin cipal, high school counselor, finan
ci
al aid
officer. or community leader:
Given my knowledge of this s
tu
dent's family circumstances a
nd
a fter
revie
wi
ng the eligibility guidelines, I believe that providing the application
fee would present a hardship. Explanation:
SCHOOL
SEAUSTAMP
*To vi
ew
USDA Income Eligibili
ty
Gu
i
de
lines f o r t h e
Free
or
Red
uc
ed Pr ice l unch Pro gram
or
r eview FAQs re lated t o t his for m v is
it
http://bi
t .ly /NACACfeewaiver .
Las
t updated 08/13
