Mental/Behavioral Health Professionals Attestation

The Chicago School has established a special tuition rate for students who are
mental/behavioral health professionals to assist eligible students with the opportunity to attend
a degree program of study at The Chicago School. To be eligible for the Mental/Behavioral
Health Professional Tuition Rate, a candidate must be accepted for admissions to the institution
and complete the Mental/Behavioral Health Professionals Attestation form and must allow for
verification of eligibility. For verification of eligibility students are required to submit
documentation of proof of employment as a mental/behavioral health professional*.

I , understand the requirements for the

Mental/Behavioral Health Professionals Tuition Rate.

I hereby certify that I am employed as a mental/behavioral health professional at:

Name of Organization Title

Organization’s Address (Street, City, State and Zip Code)

Organization’s HR Contact (Name and Phone Number)

By signing below, I attest that the information I have provided herein is true and correct to the
best of my knowledge. Also, by signing below, I give permission to allow The Chicago School to
verify my employment with the above stated organization. I understand that if, at any time or
for any reason, the employment information I have provided herein is found to be false or
untrue, I will not receive the Mental/Behavioral Health Professionals Tuition Rate benefit.

Applicant Signature Print Name Date

*You will be required to provide documentation verifying your eligibility in order to receive this special
tuition rate. Documentation verifying your eligibility must be a recent pay stub.