HRD Registration and Fee Waiver Verification - Catawba Valley Community College

First Name*

Middle name*

Last Name*

Address*

City*

State*

Zip Code*

County*

Student ID (If you have one)

Last four digits SS Number*

Date of Birth*

mm/dd/yyyy

Country (only if not US)

Citizenship Country*

Cell Phone*

Example:8283277000 (Put 0 if none)

Home Phone*

Example: 8283277000 (Put 0 if none)

Business Phone*

Example: 8283277000 (Put 0 if none)

Email*

* Required Field

Are you Hispanic or Latino?*

yes

Ethnic Origin*

Gender*

Male

Female

Other

Highest Grade of Education Level Completed*

Employment Status*

Class is needed for?*

Employment_History

(Complete if you have worked in the past 12 months start with most recent)

Employment Title 1

Start/End Date

Weeks Employed

Hourly Rate

Hours per Week

Comments

Employment Title 2

Answer if you had second employer in the past 12 months

Start/End/Date

Weeks Employed

Hourly Rate

Comments

Hours per week

Employment Title 3

Answer if you had third employer in the past 12 months

Start/End Date

Weeks Employed

Hourly Rate

Hours per Week

Comments

TUITION AND FEE WAIVER—VERIFICATION STATEMENT - The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded in the Master Course List as Human Resources Development if the individual meets on of four criteria listed below. To receive this waiver, an individual must verify that he/she meets at least one of the criteria by completing and signing this form. Students not signing this form must pay the applicable fee to register for a Continuing Education course.

I qualify for a tuition and fee waiver under the following criteria*

I am currently unemployed

I have received notice of pending lay-off

I am I am working and eligible for Federal Earned Income Tax credit

I am working and earn wages at or below (200%) of the federal poverty guidelines

(Check all that apply)

Indicate Number of dependents claimed.

(If you claim the earned income tax credit, please enter how many dependents you claim.) If none, type 0

Date*

I Verify*

Yes

I hereby verify that all the information given by me as written on this Registration and Fee Waiver Verification form is complete and accurate to the best of my knowledge.