Website - Wa



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|Student Name: ________________________________ High School:_______________________________ |

| |(A) |(B) |(A) – (B) |

|Name of College Where I Am Applying |By checking this |College |Student’s Share |Amount Requested|

| |box, I verify |Application | | |

| |that I have asked |Fee | | |

| |about the | | | |

| |college’s | | | |

| |application waiver| | | |

| |( |$ |$ |$ |

| |( |$ |$ |$ |

| Total Requested: $ |

Comments:

1. GEAR UP students may be eligible for college application fee waivers if they had a waiver for the SAT or ACT. You are required to contact the institution to determine waiver eligibility before paying the fee.

2. If it is deemed a hardship for the family/student to pay the $15 shared cost, the Coordinator may waive this fee and pay the full application fee.

3. Documentation of payment is required. This may include an email confirmation of payment or an invoice receipt from the institution. The documentation must show the student’s name, the amount of the fee, and the date of the payment.

Student Signature: _________________________________________ Date: ____________

GEAR UP Coordinator: ______________________________________ Date: ____________

Instructions:

Submit this form, along with the receipt or invoice from the college(s), with the A19 Invoice to WSAC for reimbursement.

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