Request for Waiver of Tuition Surcharge

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.)

1. Military Service Obligation
2. Serious Medical Debilitation
3. Short-term or Long-term Disability
4. Other Extraordinary Hardship

Documentation Requirements

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.