Farmingdale
State College
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Program for Tuition Assistance - Eligibility Form
(for Professional Employees in UUP Bargaining Unit as stipulated under Article 49 of the Agreement)
I am requesting enrollment in and a waiver of tuition for one course during the following semester (or
special session: _____________________________________________
Section I (to be completed by employee):
Name of Employee (print) Last Four Digits of Social Security Number
(street address) (city) (state) (zip)
(home telephone number) (business telephone number)
Section II (to be completed by employee):
Name of college/university where course is to be taken
Course Title Course Code CRN # Credits
Employee Signature
Section III (to be completed by supervisor):
Supervisor Name (print) Date
Supervisor (signature) Date
Section IV (to be completed by Human Resources):
Eligibility Approved
Ineligible - Reason: ________________________________
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Human Resources (signature) Date
Section V (to be completed by Academic Administration):
Academic Administration (signature) Date
2350 Broadhollow Road, Farmingdale, New York ● 631-420-2000
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