Application for Compassion Waiver of Society Dues Name* First Middle Last RESIDENCE Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP PhoneEmail* * I Have I Have Not previously applied for Compassion Dues Waiver from the Society. (May not exceed a three (3) month time period.)Reason for Request*Be specific. If out of work,indicate last position and name of company worked for.Certification by Member Requesting Compassion Dues WaiverThe 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 Certification of Chapter President (or, for at-large members, Society Vice-President, Membership)The undersigned certifies that all statements made herein by the applicant are true and requests that the member be granted a deferment and waiver of the Society dues for the period stated herein. Signature of Chapter President (Society VP, Membership) Date Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.