C2004-583 (Rev.4/83)
STATE UNIVERSITY OF NEW YORK
B-140W APPLICATION FOR TUITION AND FEE ASSISTANCE
PART I APPLICATION: Please complete PART I ONLY. Forward 4 copies to the appropriate officer at the campus where
you are employed. Retain the fifth copy for your records. (Separate application to be made for each semester.
Disclosure of Social Security numbers is voluntary and is used in processing student applications for tuition assistance. Authority to solicit Social Security
number has been established under Section 355 of the Education Law of New York State.
1. Applicant's Name 2. Social Security Number
3. Campus Where Employed 4. Payroll Title
5. Present Employment Status (check one)
Research Foundation Community College Employee University Employee (State Payroll)
A. To be completed by University employees on State Payroll only.
NU classified: (Check one)
01 Security 02 Administrative 03 Operational 04 Institutional 05 PEF 06 M/C
NU unclassified
08 UUP 13 M/C Professional Other (define)
6. Highest Degree Earned 7. Name of Instructing Campus
8. Please describe proposed education program (reason for taking courses listed below).
9. List courses for which approval is requested by this application:
(Approval of this request for SUNY tuition may justify a refund if tuition has already been paid. Laboratory and/or instructional fees may be included.
College Fee, Student Activity Fee and other non-instructional fees are not allowed).
Course Name(s)
Catalog
Number
Semester
and Year
Credit
Hours
Cost of Each
Course
% of Support
Requested
Amount of SUNY Assistance
Requested for Each Course
($ Total)
1.
2.
3.
10. I HEREBY APPLY FOR TUITION (AND FEE IF APPLICABLE) ASSISTANCE AS STATED ABOVE AND DECLARE MY INTENTION OF RETURNING TO MY PRESENT POSITION.
I
UNDERSTAND THAT I MUST SATISFACTORILY COMPLETE THESE COURSES TO BE ELIGIBLE FOR TUITION WAIVER.
Signature D
ATE
PART II. To Be Completed by Appropriate Officers at Employing Campus:
Complete Part II and
If instruction will be given at employing unit proceed with campus internal policy for Part III approval.
If instruction will be given at another SUNY unit, forward 3 copies to instructing unit.
11. AUTHORIZATION BY APPLICANT'S SUPERVISOR (Chair or Director) 12. VERIFICATION BY EMPLOYING UNIT'S HR OFFICE.
Authorized Signature Date Authorized Signature Date
13. APPROVAL OF CHIEF ADMINISTRATIVE OFFICER:
Application Approved for % level of support for a total amount of $ to be waived
Application Disapproved because
Authorized Signature Date
(pink copy to be utilized for employing unit pending copy)
PART III. INSTRUCTIONG CAMPUS (State-operated SUNY)
Complete Part III and Forward 2 copies (white and green) to employing campus (yellow copy retained by Student Accounts Office of instructing campus.
Application approved. Total Amount Waived $
Disapproved as submitted because
Authorized Signature Date
PART IV. Employing campus final action – Record disposition of application and distribute Affirmative Action (green) per internal procedures.
