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CALIFORNIA STATE UNIVERSITY (California State University, Los Angeles)

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Social Security:
- -
CIN:
Term and Year Course Title Level
(Undergraduate
or Graduate)
Course Subject,
Number & Section
Units Times Hours
Per
Week
WR (Work-Related ) or
CD (Career Development)
(Example)
Fall 2007 Art Undergraduate
Art 108
Visual Tech
3 8-10 am 4 Hrs CD
For work-related courses, please state how each course relates to your present assignment (attach sheets if necessary): _______
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
___________________________________ ___________ ___________________________________ _________
Date Dean/Dept. Head Signature Date
___________________________________ ___________
VP Signature
Date
____________________________________________ _________________
Signature of employee requesting fee waiver Date
EMPLOYEE’S EMPLOYMENT STATUS:
This employee is:
___Faculty or ___Staff
FLSA Status: ___Exempt ___Non-Exempt
___ Eligible for fee waiver benefits or ___ Not Eligible (Reason: _______________________________________________)
Number of units eligible for: ______Undergrad Units or ______Graduate Units (including Ed.D.)
Courses are: ___Career Development or ___Work-Related (Confirmed? Y N)
Position # _______-_______-_______ CBID: _________
Additional Fees (e.g., extra unit fee, late fees) Total: _______________ Budget Code: ___________
Fee Waiver Coordinator Signature____________________________________________________ Date__________________
Fee Waiver Coordinator Campus:____________________________ Phone Number:_________________________________
(If yes, please list days and times: _____________________________________________)
Department:
FACULTY AND STAFF EMPLOYEE FEE WAIVER APPLICATION
CALIFORNIA STATE UNIVERSITY
SECTION 1 – Employee Information (to be completed by employee for each term of enrollment)
Campus, Campus Address & Phone:
Time Base: ___Full time ___Part time
Status: __Permanent __Probationary __Temporary (appt. exp.____________)
Class Standing: __Fresh. __Soph. __Jr. __Sr. __Credential __Graduate
Name: Classification Title:
Email Address:
Do you have an approved Individual Career Development Plan on file?
___Yes ___No If yes, please indicate major:
CSU Campus to Attend:
SECTION II – Course Information
SECTION III–DEPARTMENTAL REVIEW (to be completed by employee’s supervisor)
1. Are you granting employee’s request to take one fee waiver course during regularly scheduled work hours? ___No ___Yes
My signature below is to certify that the information relevant to this request for Employee Fee Waiver is accurate and I acknowledge that I
must submit a new form if I wish to request a change (e.g., a different class, adjusted work schedule, etc.). Also, as requested by CSU policy, I
agree to provide information concerning my study program and grades received by hereby authorizing the Registrar’s Office to release my
transcript of the work completed to Human Resources. Further, I understand that CSU in no way guarantees that completion of this
coursework will result in promotion or other advancements.
OFFICE USE ONLY
2. Will the course require a change in the employee’s work schedule ? ___No ___Yes
Supervisor Signature
SECTION IV – EMPLOYEE VERIFICATION AND SIGNATURE
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CALIFORNIA STATE UNIVERSITY (California State University, Los Angeles)

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Completed 22 July 2020

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