STARTING QUARTER:
FALL
WINTER
SPRING
SUMMER
THIS FORM IS TO BE COMPLETED AND SUBMITTED TO THE OFFICE OF HUMAN RESOURCES
PRIOR TO
REGISTERING
FOR ANY UNIVERSITY COURSE.
EMPLOYEE’S NAME
Last
First
C.W.I.D
EMPLOYEE’S EMAIL
Circle One: 1. Faculty/Staff Employee
2. Spouse of Employee
3. Child of Employee 4. *Graduate/Teaching Assistant * (Out of state & International Fees Only)
Faculty and staff members (who are currently employed full-time), spouses and dependents of full-time faculty and staff are eligible for a fee waiver. The child’s birth
certificate or driver’s license must be examined by the Director of Human Resources to verify that the child has not reached the age of 24 and is the child of the employee.
The spouse and children of employees who died in service while employed by Louisiana Tech University are eligible for reduced tuition benefits.
I declare that the dependent listed below is eligible under the IRS dependent guidelines (currently under age 24, a student, and a qualified dependent).
SIGNATURES REQUIRED
APPLICABLE GROUP ABOVE
1
2
3
4
Employee
X
X
X
X
Director of Human Resources
X
X
X
X
Department Head
X
X
Dean
X
Dean, Graduate School
X
Vice President
X
President
X
EMPLOYEE, SPOUSE, AND DEPENDENT FEE WAIVER INFORMATION
Social Security Number
Name
Type Waiver
Date of Birth
Type of I.D. Presented
Employees may register for up to six (6) hours per quarter. Please list the courses and submit this form (EVERY QUARTER FOR
EMPLOYEES) prior to registering. ONE class may be taken during regular work hours. Permission to take more than one course
during regular work hours will be considered with written approval and justification from the department head and dean/division
head and the President prior to registering.
COURSES:
1.
2.
3.
4.
PLEASE NOTE: Employee & Dependent Fee Waiver Forms may not be used for Extension Courses.
Employee & Dependent Fee Waiver Forms may not be used in conjunction with Fee Waivers: National Guard, SGA, Titles 29 & 33
For more information on policies and procedures regarding fee waivers you may go to http://www.latech.edu/tech/administration/policies-and-procedures/1421.html
Revised September 2012
LOUISIANA TECH UNIVERSITY
EMPLOYEE TUITION BENEFIT FORM
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