Last Name

First Name

Middle Initial

Student 92#

Telephone

Catamount Email Address

Address (Number and Street, City, State, Zip)

Semester/year for which you are requesting a waiver: (May not be prior to Fall 2009.) :

Year

Semester Fall Spring

Choose one of the following waiver categories, or, Summer Hours Review:

Waiver Category Military Service Obligation Serious Medical Debilitation Short-term or Long-term Disability Other Extraordinary Hardship Summer Hours Review

Student: Describe the circumstances that support your waiver request above. You may attach additional pages as necessary. Attach the necessary documentation requirements that correspond with the waiver category selected above.

Please note: Health information submitted with a request of waiver of tuition surcharge is considered a disclosure authorized by the student.

Description