Application for Compassion Waiver of Society Dues

Please complete the form in its entirety. If an incomplete form is submitted, the applicant will be requested to reapply.

Name*
Prefix First Middle Last Suffix
RESIDENCE Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
Have you previously applied for a Compassion Dues Waiver from the Society?*
(Applications are reviewed on a case-by-case basis.)
- Yes
- No
Reason for Request*
Be specific. If out of work, indicate last position and name of company worked for.
Certification by Member Requesting Compassion Dues Waiver*
The undersigned certifies that all statements made herein are true and, if granted a deferment and waiver of the Society dues, agrees to abide by the conditions stated herein.

Signature of Member Date
Certified Statement Letter from Chapter President*
A letter from the Chapter President supporting your request MUST be submitted with this form.
Max. file size: 100 MB.

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A Compassion Waiver of Dues will only be granted for a maximum of a three (3) month increment, with a maximum amount of four (4) waiver renewals permitted. It shall be the responsibility of the member and the Chapter President to immediately inform the Society’s Membership Coordinator/Manager/Director or CEO/Executive Director when the condition for which the Compassion Waiver of Dues has been granted ceases to exist.

Application for Compassion Waiver of Society Dues

Application for Compassion Waiver of Society Dues

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