Employee – Print Name Employee’s Signature Date
As the Human Reso
urces Representative,
I
have
verified
that
the employee
listed above is eligible to participate in the fee
waiver program. Fee Waiver Coordinator:_________________________________________ Date:_________________
Submitted to Accounting on: _________________
DEPENDENT FEE WAIVER APPLICATION
SECTION III – EMPLOYEE VERIFICATION AND SIGNATURE
I certify that the individual named above is my legal spouse, dependent child, or registered domestic partner
(Dependent) and that the information provided above is true. I wish to transfer my fee waiver eligibility, as provided in
appropriate policy or collective bargaining agreement, to the individual named above. I understand this transfer prohibits
my personal use of fee waiver benefits during the period indicated. Further, I understand that my spouse, dependent child
or domestic partner is responsible for meeting all registration and payment deadlines and informing the Human Resource
office if any changes in approved fee waiver classes occur.
Students participating in this program must be in good academic standing. Academic standing will be reviewed each
semester to determine eligibility to participate in the subsequent semester. ‘Good Academic Standing’ does not include
Probation, Disqualification, Contract status or Administrative Approved Academic Probation.
For information on Academic Probation: http://www.csufresno.edu/studentaffairs/programs/advising/disquali.shtml
If my Dependent is attending CSU, Fresno, a confirmation of enrollment listing the courses and the units per course is
attached to my application. Applications will be considered incomplete and will be returned if this information is not
attached.
I understand that fees waived on behalf of an employee’s legal spouse, dependent child, or registered domestic partner for
enrollment in graduate-level courses may be reported as taxable income for the employee. All undergraduate
level course work taken by an employee’s domestic partner through this program is taxable as well.
All fees should be paid directly to the cashier in the Joyal Administration Building. If there are any questions regarding E-
pay or other payment options, please contact Students Accounts at (559)278-2876.
Student may contact the Admissions office at (559)278-2261 (Undergrad Admission) or (559)278-4072 (Grad Admission)
to request a one time reimbursement of the CSU Application Fee ($55).
I UNDERSTAND THAT THE STUDENT MAY ALSO BE CHARGED FULL OR PRORATED
REGISTRATION FEES IF THE STUDENT DROPS CLASSES FOR WHICH THE STUDENT HAS BEEN
GRANTED A FEE WAIVER. THE WAIVER WILL BE REMOVED AND FEES WILL BE CHARGED UP TO
THE FULL AMOUNT AS OF THE DATE OF THE CLASS WITHDRAWAL.
See Accounting Services web page for more information.
As an employee, I have read and understand the conditions of the Fee Waiver Program which can be found on
theTechnical Letter HR Benefits 2011-14 and my Collective Bargaining Agreement.
Page 2 of 2
Please submit completed forms to Human Resources
M/S JA 41 or fax to 559/278-4275
Human Resources, Joyal Administration Building
Room 211, (559) 278-2032
Rev. 3/2018
