REQUEST FOR ULS PPM: FB.IV.V.0.LA TUITION REDUCTION
COMPLETE ONE FORM FOR EACH ELIGIBLE PERSON FOR EACH SEMESTER
EMPLOYEE NAME: _________________________________ N#_____________________ FACULTY STAFF
SEMESTER REGISTERING FOR: FALL SPRING SUMMER YEAR ______
CAMPUS PHONE #: ____________________ FULL-TIME EMPLOYMENT: YES NO
PERSON FOR WHOM EXEMPTION IS BEING CLAIMED: (if for employee, please select undergraduate or graduate)
UNIVERSITY ATTENDING ___________________________________________________
EMPLOYEE STUDENT ID#:___________________________________________ UNDERGRADUATE GRADUATE
(of university attending if exemption is for employee)
________________________________________________________ ____________________________________
Signature of Faculty or Staff Member Supervisor Date
DEPENDENT: SON/DAUGHTER SPOUSE (UNDERGRADUATE)
DEPENDENT NAME _______________________________ ID#______________________
(if exemption is for dependent) (of university attending)
SPOUSE NAME ___________________________________ ID# ______________________
(if exemption is for spouse) (of university attending)
I CERTIFY THAT THE FOREGOING INFORMATION IS CORRECT.
________________________________________________________ ____________________________________
Signature of Faculty or Staff Member Date
________________________________________
Approval of University Presidents needed for employees/dependents attending other Universities only
________________________________________ ________________________
Nicholls State University President Signature Date
_______________________________________ ________________________
University President Signature Date
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