Statewide & Health Workforce Shortage Programs
Enrollment Verification
_____________________________________________________________________
Complete this form to request in-county tuition if you are enrolled in one of the programs listed below and reside
in Maryland, but outside of Montgomery County.
Submit one form each semester at the time you register to the Office of Admissions and Records.
Forms may be used for summer and winter courses, but they are processed by the Office of Institutional Research
and Analysis after the third week of classes in the fall and spring semesters only.
Financial adjustments to student accounts are made at the end of November and March.
Name ______________________________________________________ Student ID M- _________________________
County of Residence _______________________________________
Tuition Adjustment Requested for Semester __________________________ Year _____________________________
I understand that I am eligible for the in-county rate only for courses applicable to the program of study indicated below:
Social Security Number* ____________________
* Montgomery College is required to report your Social Security Number to the State of Maryland for this process.
Designated Statewide Programs
Lower Division Certificates:
Technical Writing (143)
Fire & Arson Investigation (180)
Fire Protection Tech (248)
Fire Prevention Tech (247)
Health Workforce Shortage Programs
Lower Division Certificates:
Associate Degrees:
Radiologic (X-ray) Technology (340)
Diagnostic Medical Sonography (335)
Nursing (400)
Health Information Management (349)
Mental Health Associate (338)
Physical Therapy Assistant (300)
This student was advised by me and is registering for appropriate courses in the designated curriculum.
_______________________________________ __________
Student Signature Date
Office Use Only
Office of Admissions and Records
This student is eligible for participation in the Statewide or Health Workforce Shortage programs as indicated above. The
student resides in a participating Maryland county and is taking the following eligible credits:
Overall Enrolled Credits ________________________ Credits Eligible for Funding ____________________________
_________________________________ _______________________________________ _________________
Registrar Printed Name Registrar or Designee Signature Date
ES 07/27/2016
Received by ________________________ Date ____________________________
____________________________________ _______________________________________ ______________
Program Coordinator Printed Name Program Coordinator Signature or Designee Date
Copy made for student
NO hold added
Graphic Design, AFA (902)
Studio Art, AFA (900 and 910)
Associate Degrees:
Fire and Emergency Services Management (346A)
Fire Prevention Technology (321)
Fire Protection Technology (322)
Polysomnography Technology (243)
Biotechnology (334)
Surgical Technology (352)
*** Recent changes in State funding may alter the availability of this program for upcoming terms. Diagnostic Medical
Sonography and Surgical Technology Certificates removed Spring/Summer 2013***
