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Please note that extreme economic hardship includes, but is not limited to, the following: 1) Currently qualifying for food stamps, temporary assistance to needy families, unemployment benefits, Medicaid, or other federal financial assistance based on economic need. 2) Currently qualifying for a federal Pell grant or other student grant program based on economic need. Note: student loans are not grants. 3) Currently qualifying for local, state or other financial assistance programs administered by a government agency or private charity.
Please include any supporting documentation, such as copies of transcripts, proof of date of Ph.D., proof of K-12 employment or studies, or other documents to support your waiver request.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf pdf doc docx.

With my signature below, I affirm that the above statement is accurate and true. I understand that misrepresentations on this form may result in a loss of the waiver and other such membership privileges as appropriate.