BURSAR OFFICE
Request for Approval of Graduate Staff Fee Remission
Bursar Office Form 1003 – Revised 05/03/16 PLEASE PRINT CLEARLY
A NEW FORM MUST BE SUBMITTED FOR EACH TERM YOU ARE REQUESTING REMISSION.
All forms must be completed in full in order to be processed. Incomplete forms will be returned to staff member. Please review the policy on the back
of this form. This form must be submitted to the Graduate Studies Office NOT LATER THAN 3 WEEKS FROM TIME OF APPOINTMENT
(employment start date must be within the first 6 weeks of the term to qualify for remission).
Section A – Please complete the following employment information:
Name: __________________________________________ Student ID Number: ____________________________
Employing Department: ____________________________ Employing Campus: ____________________________
Position Title:
Grad Profess. Resrch. Asst. Teach Asst.
Graduate Staff Appointment Date: _________________
Appointment % of Full Time:
.25CUL .50 CUL
Over .50CUL*
Office Phone Ext: ___________________
*If above .50 CUL, the supervisor signing this form must request approval from the VCAA and submit a copy of the approval form with this request.
Complete this section only if requesting remission for summer and you will not hold a graduate staff appointment during the summer.
1. Did you hold a graduate staff position during the past spring semester? _____ Yes _____ No
2. Will you hold a graduate staff position during the next fall semester? _____ Yes _____ No
3. When will you complete your degree requirements? Month _____________________ Year ____________
Section B – Please complete the following enrollment information:
Fall 20_______ Spring 20_______ Summer 20_______
Student Enrollment Information
Course Schedule: Days/Time
Subject Course Number (not CRN) Credit Hours
Total Hours
Student – Please list other graduate staff appointments, student hourly appointments or any other employment within the Purdue
University system (any campus):
Employing Department Employing Campus Hourly or Grad Staff
Appt. Hours per week
Start Date
*I certify that I am enrolled as a Purdue University graduate student in a degree or teacher license program. Based on my graduate staff appointment,
I hereby request a graduate fee remission. I understand that my graduate staff appointments, either alone or in combination with other grad
staff appointments or student hourly employment, may not exceed .50 CUL (half-time). Any exceptions to this policy must be pre-approved by
the Vice Chancellor of Academic Affairs. By signing this form, I certify that my employment at Purdue University (any campus) does not exceed .50
CUL. Additional employment with any Purdue University campus (beside this appointment) must be disclosed on this form. If additional positions
are obtained after submission of this fee remission, I understand that my total concurrent employment may not exceed .50 CUL (half-time).
Requested: ___________________________________________________________ Date: _________________________
(Student*)
I certify that the graduate staff appointee listed above is eligible for a graduate fee remission in accordance with University policy.
Recommended: _______________________________________________________ Date: _________________________
(Employing Department Head)
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Approved Not Approved ___________________________________________ Date: _________________________
(Director, Graduate Studies Office)
Bursar Office Use Only: Date Entered ______________Initials____________
Hammond Campus
2200 169
th
Street Hammond, IN 46323
(219) 989-2560 bursar@pnw.edu
Westville Campus
1401 S. U.S. Hwy. 421 Westville, IN 46391
(219) 785-5338 bursar@pnw.edu
