Waiver Request Form

1. Waiver requested for: (Check all that apply)

Medical Hardship
Economic Hardship
Other Emergent or Humanitarian Need (Explain)

2. Have you requested a waiver before?

Yes (Explain)
No

3. Approximately how long have you been in this situation?

4. Please provide a detailed description of your current situation that requires you to request this wiaver; i.e.: Describe the type of dwelling or vehicle damaged.

5. Please check which corroborated evidence you are providing. This evidence is required. (Hardships may not be mutually exclusive. Please provide all documentation to consider if requesting a combination [ie, medical and economic) hardship waiver.)

Medical Hardship

Letter from treating physician (on Doctor's letterhead) stating diagnosis and prognosis of medical condition
Other supporting documentation relevant to the medical condition and its impact on being able to practice medicine/surgery

Economic Hardship

Copy of FEMA inspection report
Copy of FEMA check or FEMA letter describing how you are to use the assistance money
Copy of insurance claim filed

Other Emergent of Humanitarian Need:

Letter of corroboration
Other supporting documentation

6. Explain how your practice will be affected if you cannot retain your NSAA membership.*

7. Why should you be granted a dues reduction or dues waiver?*

I wish to appeal to the NSAA to grant a Membership Dues Waiver or Dues Reduction so that I may retain NSAA membership and maintain my CSA certification eligibility through the NSAA.

Signature

Date*

Step 1 of 2 - Demographics