EMPLOYEE AND/OR DEPENDENT TUITION WAIVER FORM
Employee’s Name Employee ID # &Position/Title
(please print)
Phone # Email
Dependent’s Name Dependent’s Student ID or SS#
Phone # Email
Relationship to Employee: (check one)
Self Spouse Unmarried Natural or Adopted Child Unmarried Step-Child Legal Ward
Institution to Attend Term/Year
Course #
Course Name
Credit Hours
Online: Yes No
Audit: Yes No
Course #
Course Name
Credit Hours
Online: Yes No
Audit: Yes No
Course #
Course Name
Credit Hours
Online: Yes No
Audit: Yes No
Course #
Course Name
Credit Hours
Online: Yes No
Audit: Yes No
Course #
Course Name
Credit Hours
Online: Yes No
Audit: Yes No
I certify that I am familiar with the provisions of the Employee and/or Dependent Tuition Waiver policy and that the person(s) requesting the tuition waiver
benefits qualifies as an eligible employee or dependent in accordance with the policy. (See reverse of form for policy and/or processing steps).
INITIAL BY EACH ITEM
AND SIGN BELOW
All fees (other than portion of tuition waiver), books and supplies are the responsibility of the student
Maximum of one audit per term
Waiver does not apply to repeated courses
Student must abide by the academic limitations and policies of the attending institution (including any course limitations)
Unofficial Transcripts (and current course schedule) must be attached to this form
It is the responsibility of the employee and/or dependent to ensure that all documents and forms (requested by the college where the student is enrolled) are
submitted and signed by the appropriate personnel in a timely manner prior to submission. Any packets deemed as incomplete will cause a delay in the processing
of the tuition waiver. Please be sure to check with the college in which you are registered for courses to ensure the packet is complete.
Date
Supervisor (if required)
Date
This section to be completed by the Human Resources department at the institution of employment.
Certification:
Full Waiver
2/3 Waiver
1/3 Waiver
Full-time Employment Date
Date of Employee
Retirement
*Dependents are eligible for waiver for a maximum of 5 years from date of employee retirement.
Certifier Name:
Title:
Date:
Employee’s Institution: ___________________________________________
This section to be completed by the appropriate college official at the institution of attendance.
Certification:
Student’s GPA is at least 2.0?
Yes
No
Certifier Name:
Title:_____________________
Dept/Division:
Date:
This section to be completed by the President at the institution of attendance.
Based on the certified information above, I hereby certify that
has been approved to receive all benefits granted under
the Employee and Dependent Tuition Waiver Program for
hours at the institution of
President:
Date:
Notes:
Revised May 2020
Does the Dependent live with you? Yes No With former Spouse? Yes No Temporary Housing? Yes No
(The unmarried child(ren) must reside in the household of the employee or
retiree. The unmarried child(ren) must reside in the household of the employee’s or retiree's former spouse. The
unmarried child(ren) must reside in temporary housing while enrolled in college such as college dormitories, apartments, and student housing. The unmarried stepchild(ren) must reside in the
household of the employee or retiree. Dependent refers to spouse, unmarried child(ren) or a legal ward (minor child placed by court) when the guardian is a benefits eligible employee or retiree.)
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