Instructions
Re-Entry Center
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R E Q U E S T TO C O V E R H E A LT H I N S U R AN C E C O S T S
ST UDENT 'S INFO RMAT IO N
Last Name
NSHE ID
First Name
Email Address
Request is for Term and Year(Ex: Fall 2016)
Main Telephone Number
Alternate Telephone Number
Program of Study
Subsidizing Health Insurance Notice
Health insurance costs can only be covered by TMCC's Re-Entry Center if the insurance is required by your course and
study and you cannot afford to pay for it yourself.
PERSO N AL ST AT EMENT
I request that the TMCC Re-Entry Center pay my health insurance fees for the following reason:
Signature of Applicant
Page 1 of 1; Request To Cover Health Insurance Costs
TMCC is an EEO/AA institution. See http://eeo.tmcc.edu for more information.
Date
Created: 9/28/2015; Rev: 9/29/2015