SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE
BOARD OF GOVERNORS
SCP-5065.A
Employee Tuition Waiver Application
REFERENCE: SCP-5065, Awarding of Undergraduate Tuition and Fee Waivers;
SCP-2165, Educational Release Time for Classified Employees
Instructions to Employee: All full-time regular, benefits eligible employees seeking an Employee Tuition Waiver for themselves
or eligible dependent(s) as defined by SCP-5065, must complete this form and submit it to the Office of Student Financial Assistance
prior to the beginning of the semester. A separate form must be completed and filed for each eligible individual. A new form must
be completed and filed each semester for which a tuition waiver is requested. Student fees (i.e., course lab fees, wellness fee, etc.) are
not covered by this waiver and must be paid by the student by the due date for the term in which the student is enrolled. Employees
should assure that the dependent for whom they are requesting tuition benefits has (1) completed high school or earned a GED, is not
married, and is less than 24 years of age on the first day of classes of the term for which he/she wishes to register for which the tuition
waiver is provided; and (2) completed an admissions application to Southern.
Semester and year waiver will be applied : G Fall G Spring G Summer 20 ____ (year)
_____________________________________________________________ _______________________
Student Name
(If waiver is for eligible dependent, employee information is also required) Student ID Number or SSN
Relationship to Employee: G Self G Spouse G Dependent Child ________ High School/GED Graduation Date
Does applicant hold a college degree? G Yes G No If yes, highest degree held: G Associate G Bachelors G Masters or above
__________________________________________________________ _______________________
Employee Name
(If student is eligible dependent) Employee ID Number
CRN Dept. CRS No. Section Course Title Days Time CR.
Enrollment in Course Conflicts with Regular Work Hours (Classified Employees Only): If enrollment in a course conflicts
with the regular working hours of a classified employee, the supervisor’s prior approval is required as specified in SCP-2165.
This must be obtained before the employee submits this form or registers for the course.
____________________________________________ ____________________________________________
Supervisor’s Signature Date Unit Supervisor’s Signature Date
I certify that I am eligible for this tuition waiver for myself and/or eligible dependent(s), and that I may be subject to loss of benefit for
providing false information.
Employee Signature:
Date:
Verification of eligibility for tuition waiver: G Approved G Denied Verification Completed by _____________________________ Date _______________
COURSE REGISTRATION: Completing this form does not enroll the applicant in the desired course(s). Enrollment is the applicant’s responsibility.
See the registration website at www.southernwv.edu
for complete information.
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Originated 12/2012
