Date of last revision: 8/14/08
VERIFICATION OF EMPLOYMENT: DATE:
Signature of CCSNH Human Resources or College President
DEPENDENT INFORMATION (if applicable)
TO EMPLOYEE: Civil Union Partner
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?
I certify that the above information is true and correct.
Employee Signature Date
CCSNH COLLEGE AT WHICH COURSE(S) WILL BE TAKEN
COURSE DEPT/# COURSE TITLE SEMESTER
APPROVAL BY PRESIDENT OR DESIGNEE OF CCSNH COLLEGE OFFERING THE COURSE(S):
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
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).