Minimum Content Required for the Tuition Surcharge Waiver
Student’s Name ________________________________________________________________
Student’s Address ______________________________________________________________
Student’s Identification Number ___________________________________________________
Student’s Major(s) / Degree Program________________________________________________
Basis for Waiver Request ________________________________________________________
The following four waiver categories constitute the only grounds for waiver of the tuition surcharge (Select one of the following. Please see policy for explanation.)
Attach to this form the necessary documentation requirements that correspond with the waiver category selected in Section II. Documentation not included with this form will not be considered.
Form Completion and Submission
Once this form has been timely completed in its entirety, including the necessary information and documents listed in sections I, II, and II, the form shall be submitted to the institution for consideration.
Please submit correspondence to:
University of North Carolina at Pembroke
PO Box 1510
One University Drive
Pembroke, NC 28372-1510
Attn: Ms. Sharon Kissick, University Registrar
This publication is available in alternative formats upon request.
Please contact Disability Support Services, DF Lowry Building, 521-6695.