Northwestern Connecticut Community College • Park Place East • Winsted, Connecticut 06098 -1710
Phone: (860) 738-6300
www.nwcc.commnet.edu
APPLICATION AND CERTIFICATION FOR EXEMPTION FROM PAYMENT OF THE
APPLICATION FEE, MATRICULATION FEE AND ALL GENERAL FEES
Student ID # @____________________
OR
Social Security # ______/_____/______
Name of Student:_______________________________________
Address: ____________________________________________________________________________
(Street)
(City, State, Zip)
Application is hereby made for waiver from payment of the application fee, matriculation fee and all
general fees at Northwestern Connecticut Community College for: _____ Employee
_____ Spouse
_____ Dependent child
Semester:
Year _______
_____ Fall
_____ Spring
_____ Summer
CERTIFICATE OF EMPLOYEE
(To be completed only if the applicant is the spouse or a dependent child of a full-time Connecticut
Community College employee)
Name of Employee:___________________________________________
Address of Employee:________________________________________________________________
(Street)
(City, State, Zip)
This is to certify that the above named student is my spouse or dependent child.
____________________________________________
Signature of Employee
________________
Date
CERTIFICATE OF EMPLOYER:
This is to certify that the above named employee is employed full-time within the Connecticut
Community College System at Northwestern Connecticut Community College
__________________________________________
Name:
Title:
_________________
Date
A Member of the Connecticut Community College System
An Equal Opportunity Employer