Student Affairs—Admissions/Records/Enrollment Services
4501 Amnicola Hwy., Chattanooga, TN 37406-1097
Return this Application as an attachment to email@example.com
Name (please print):
Last First Middle
Date of Birth: / / Student ID (A Number):
Term of Enrollment Fall 20 Spring 20 Summer 20
Street Address - must be the same as on file:
City, State, ZIP - must be same as on file:
County of Residence: Phone: ( )
I certify that I am eligible for this waiver and that the information presented is true and correct.
Student Signature: Date:
This section must be completed by the employer, dated, and submitted to Chattanooga State Community College within two weeks of fee payment.
City: State: ZIP:
I am authorized to complete this verification and certify the above named person is a full-time employee with a reasonable expectation of
continued full-time employment.
Name and Title of Certifying Official:
Office Phone: ( )
TBR Policy 3:05:01:00 provides that part-time students who are non-Tennessee residents but employed full-time in Tennessee are exempt from paying out-
of-state tuition and are allowed to pay in-state fees. To qualify for the out-of-state tuition exemption, you must provide verification of
full-time employment each term. Full-time students do not qualify for this exemption but may qualify for other waivers. Out-of-state tuition will be removed
when the employment verification is received. However, all information is subject to internal and external audit. Submission of false or unverifiable
documentation may result in additional fee-payment obligations and/or immediate dismissal without refund. Registration for more than 11 hours will
result in automatic calculation and responsibility for out-of-state tuition. You and your employer may complete this form or your employer may submit
equivalent verification using official company stationery. In the event the company owner and the student are the same or related, state and/or federal
employer identification information, business license information and/or earnings records may be required as proof of full-time employment in Tennessee.
*Verification of Tennessee
employment is invalid if
dated earlier than 2 weeks before fee
Pub. No. 11-70-501001-105-8/14/sf/bap • Form 23 • 1 PDF • Chattanooga State Community College is an AA/EEO employer and does not discriminate on the
basis of race, color, national origin, sex, disability or age in its program and activities. The following person has been designated to handle inquiries regarding
the non-discrimination policies: Director and Affirmative Action Officer, 4501 Amnicola Highway, Chattanooga, TN 37406, 423-697-4457.