Application Fee Waiver Update Final (1).pdf - Request for...

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Request for Admission Application Fee Waiver TO: Office of Admissions, University of Arkansas at Pine Bluff, Mail Slot 4892, 1200 N. University Drive, Pine Bluff, AR 71601 or fax it to UAPB Admissions Office at 870-575-4607 STUDENT: Print or type the information requested below. You must personally sign the Certificate Statement. CERTIFICATE 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 PHONE NUMBER EMAIL ADDRESS AUTHORIZED OFFICIAL: Print or type the information requested below and check the indicator(s) of eligibility. You must personally sign the Certificate Statement. CERTIFICATION STATEMENT : I certify that the student named on this form is currently enrolled in the 11 th or 12 th grade at this school and meets the eligibility for waiver as checked below. _____________________________________________________________________________________________________________________ AUTHORIZED OFFICIAL’S NAME AUTHOR IZED OFFICIAL’S SIGNATURE _____________________________________________________________________________________________________________________
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Unformatted text preview: AUTHORIZED OFFICIAL’S TITLE AUTHORIZED OFFICIAL’S EMAIL _____________________________________________________________________________________________________________________ NAME OF SECONDARY EDUCATIONAL INSTITUION OR ORGANIZATION CEEB OR PROGRAM” _____________________________________________________________________________________________________________________ ADDRESS PHONE AU WAIVER CRITERIA: Check all that apply. THORIZED OFFICIAL: Print or type the information requested below and check the indicator(s) of eligibility. You must personally sign the Certificate Statement. Student is enrolled in a federal, state or local government funded program that aides students from low income families (e.g., Upward Bound). Student claims Legacy Status. A student may claim Legacy Status as a child or grandchild (age 26 or under) of a UAPB/AM&N graduate who is a current annual dues paying member or a Life Member of the UAPB/AM&N National Alumni Association. Student must provide the full first and last name of the parent or grandparent as it appears on the UAPB/AM&N National Alumni roster. Send this form to the Association at [email protected] for verification of Legacy Status. __________________________________________ Alumni Parent/Grandparent Full First and Last Name...
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