Senior Citizen Form by VlMQV56


									                    University System of Maryland
             Senior Citizen Request for Tuition Remission

Name: ___________________________ Social Security Number:___________
      Last, MI, First

Street Address: ____________________________ City: __________________

State: __________ Zip Code: ______________ Phone: _________________

Semester Applying: Check one

_____Fall            _____Spring

_____Winter          _____Summer I or _____Summer II

Academic Year: ________

Dept.     Course Section               Course Title              Credit     Meeting Times

Senior Citizens are eligible for up to 3 classes per semester.

I certify that I am at least 60 years of age and retired, that my chief source of
income is derived from retirement benefits, that I am not engaged in full-time
employment, and that I am a Maryland resident.

___________________________            _______________________
Senior Citizen Signature               Date

___________________________            _______________________
Authorized HR Signature                Date

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