Date of last revision: 8/14/08
EMPLOYEE
NAME:
POSITION
TITLE:
HOME
INSTITUTION:
DATE OF
FULL-TIME HIRE:
VERIFICATION OF EMPLOYMENT: DATE:
Signature of CCSNH Human Resources or College President
DEPENDENT INFORMATION (if applicable)
DEPENDENT
NAME:
RELATIONSHIP Spouse
TO EMPLOYEE: Civil Union Partner
Child
DEPENDENT DATE OF BIRTH
Is the child unmarried?
Was the child listed as an exemption on the Employee’s or Spouse’s/Civil Union Partner’s
most recent income tax return?
Does the child rely on the employee for more than half of their financial support during the calendar year?
Yes No
Yes No
Yes No
I certify that the above information is true and correct.
Employee Signature Date
CCSNH COLLEGE AT WHICH COURSE(S) WILL BE TAKEN
PROGRAM/COURSE(S) DESIRED:
COURSE DEPT/# COURSE TITLE SEMESTER
(Beginning Month/Year)
APPROVAL BY PRESIDENT OR DESIGNEE OF CCSNH COLLEGE OFFERING THE COURSE(S):
SIGNATURE DATE
CERTIFICATION
I understand that by registering for course(s) at a CCSNH College, I am financially obligated for tuition or any associated fees, if applicable.
I further understand that if I do not make payment in full, my account may be reported to the credit bureau and/or turned over to a
collection agency. I also understand that I will be responsible for the costs of collection on my account, including any collection agency,
legal, and/or returned check fees under RSA 6:11, which may add significant costs to my account balance.
Dependent Signature (if applicable) Date Employee Signature Date
COMMUNITY COLLEGE SYSTEM OF NEW HAMPSHIRE
TUITION BENEFIT AUTHORIZATION FORM
EMPLOYEE INFORMATION
COURSE INFORMATION
A registration form must accompany this request. This approval must be presented to the cashier of the Business Office
with proper form of identification when registering for course(s).
