Revised 7/10
Fee Waiver Application - Employee
EMPLOYEE INFORMATION (to be completed by employee for each term of enrollment)
Contact Information:
Campus Address:
Campus Phone:
Fax:
Current Educational Level:
Freshman Sophomore Junior Senior
Graduate
Time Base: Full-Time Part-Time
Status: Permanent Probationary Temporary (appt, exp.____________)
Level (Undergrad
or Grad)
Course Subject,
Number & Section
WR (Work-
Related) or
CD (Career
Development)
For work-related courses, please state how each course relates to your present assignment (attach sheets if necessary
EMPLOYEE VERIFICATION AND SIGNATURE
My signature below certifies that the information relevant to this request for Employee Fee Waiver is accurate and I acknowledge that I must submit a new form if
I wish to request a change (e.g., a different class, adjusted work schedule, etc.). also, as requested by CSU policy, I agree to provide information concerning my
study program and grades received by hereby authorizing the Registrar’s Office to release my transcript of the work completed to Human Resources. Further, I
understand that CSU in no way guarantees that completion of this coursework will result in promotion or other advancements.
_________________________________________________________________ ___________________________________
Employee’s Signature Date
NOTE: A completed “Career Development Plan” must accompany this form.
1. Are you granting the employee’s request to take one fee waiver course during regularly scheduled work hours? Yes No
2. Will the course require a change in the employee’s work schedule? No Yes
_______________________________________ ______________ ___________________________________ _______________
Supervisor’s Signature Date Vice President’s Signature Date
Fax this form to the Human Resources Department at (707) 654-1141
HUMAN RESOURCES OFFICE USE
This employee is Faculty Staff FLSA Status: Exempt Non-Exempt
Eligible for Fee Waiver Yes No (Reason for not eligibile) ________________________________________________
Number of units eligible for: ______ Undergrad units _____ Graduate Units Courses are Career Development or Work-related
Position #______________________________ CBID _______________________
Additional Fees (e.g., extra unit fee, late fees) Total _________________ Budget Code: ________________
CSUM Fee Waiver Coordinator: __________________________________________________________ Date: _______________________
Attending Campus Fee Waiver Coordinator:_________________________________________________ Date:________________________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
