PUBLIC HIGHER EDUCATION FEE WAIVER
FOR EMPLOYEES OF STATE OF TENNESSEE
Higher Education Institution:
Term: Fall Spring Summer Other Year:
Phone No.:
Employee/Applicant Information
Full Name:
Edison ID No
.:
Address:
City, State, Zip Code:
Employmen
t by State of Tennessee
: Full-Time Part-Time
Employed by State for six continuous months or more
Department:
Work Location:
Title:
Phone No.:
City
Under the penalties of perjury, I certify that I am currently employed by the State of
Tennessee as described above, with at least six months continuous State service, scheduled
to work 1,950 or more hours per year, or scheduled to work 1,600 or more hours and
receiving all benefits provided to full-time State employees; that I have received a copy of
the rules and regulations for the fee waiver program and that I am eligible under the rules;
and that all of the above information is true, correct, and complete. If following enrollment I
am found to be ineligible for this benefit, I acknowledge that I will be responsible for
payment of all previously waived fees plus any other applicable charges.
Signature: Date:
EMPLOYER’S CERTIFICATION
I certify that the above named employee/applicant is currently employed by the State of
Tennessee as described above, with at least six months of continuous State service, is
scheduled to work 1,950 or more hours per year , or scheduled to work 1,600 or more hours
and receiving all benefits provided to full-time State employees, and to the best of my
knowledge is eligible for this fee waiver program.
Signature:
Title:
Date:
Address:
City, State, Zip Code:
FOR INSTITUTIONAL USE
Eligible Fee Waiver Amount: $
Accepted By: Date:
HE0006
Phone No.:
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