PART I APPLICATION: Please complete PART I ONLY
Disclosure of Social Security numbers is voluntary and is used in processing student application for tuition assistance. Authority to solicit Social Security number has been
established under Section 355 of the Education Law of New York State.
1. Applicant’s Name ___________________________________________________________________________________________
2. Social Security Number ____________________________ 3. Stony Brook ID Number_________________________________
4. Email Address ____________________________________________________________________________________________
5. Campus Address____________________________________Zip_____________________Phone Number____________________
6. Campus Where Employed _________________________ 7. Job Title ___________________________________
8. Present Employment Status (check one) Research Foundation Community College Employees University Employee
9. To be completed by University employees on State Payroll only.
NU classified: ( Check one)
01 Security 02 Administrative 03 Operational 04 Institutional 05 PEF 06 M/C
NU unclassified
08 UUP 13 M/C Professional Other (define)______________________
10. Highest Degree Earned:_________________________ Name of Instructing Campus you will be attending ___________________
Please describe proposed education program (reason for taking courses listed below).
11.List courses for which approval is requested by this application:
(Approval of this request for SUNY tuition may justify a refund if tuition has already been paid. Laboratory and/or instructional fees may be included. College Fee, Student
Activity Fee and other non-instructional fees are not allowed.)
Course Name (s)
Catalog
Number
Semester
And Year
Credit
Hours
Cost of Each
Course
% of Support
Requested
Amount of SUNY Assistance
Requested for Each Course ($ Total)
1.
0.00%
2.
0.00%
3.
0.00%
I HEREBY APPLY FOR TUITION (AND FEE IF APPLICABLE) ASSISTANCE AS STATED ABOVE AND DECLARE MY INTENTION OF RETURNING
TO MY PRESENT POSITION. I UNDERSTAND THAT I MUST SATISFACTORILY COMPLETE THESE COURSES TO BE ELIGIBLE FOR TUITION
WAIVER.
Signature ______________________________________________________________________________ Date ______________________________________________
12. Part II. To Be Completed by Appropriate Officers at Employing Campus
Complete Part II and
If instruction will be given at employing unit proceed with campus internal policy for Part III approval.
If instruction will be given at another SUNY unit. Forward 3 copies to instructing unit
AUTHORIZATION BY APPLICANT’S SUPERVISOR (Chair or Director) VERIFICATION BY EMPLOYING UNIT’S HR OFFICE
_____________________________________ __________________ ___________________________ _____________________
Authorized Signature Date Authorized Signature Date
APPROVAL OF CHIEF ADMINISTRATIVE OFFICER:
Application Approved for __________% level of support for a total amount of $______________ to be waived
Application Disapproved because ______________________________________________________________________________
_____________________________________________________ _________________________________________
Authorized Signature Date
13. Part III. INSTRUCTING CAMPUS (State-operated SUNY)
Complete Part III
Application approved. Total Amount Waived $_________________ Disapproved as submitted because ____________________________________________
_______________________________________________________________________ ___________________________
Authorized Signature Date
