STATE UNIVERSITY OF NEW YORK
B-140W APPLICATION FOR TUITION AND FEE ASSISTANCE
PART I. APPLICATION
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 the State of New York.
1. Applicant's
C2054-583 (rev. 4/83)
Name 2. Person Number
3. Campus Where
Employed 4. Payroll Title _
5. Present Employment Status (Check one) Research Foundation Employee Community College Employee University Employee (State Payroll)
A. To be completed by University employees on State Payroll only.
Negotiating Unit: (Check one) 01 Security 02 Administrative 03 Operational
04 Institutional 05 PEF 06 M/C Classified
08 UUP
13 M/C Professional
Other (Define)
6. Highest Degree Earned 7. Name of Campus You Will Be Attending
8. PLEASE DESCRIBE PROPOSED EDUCATIONAL PROGRAM (Reason for taking below-listed courses).
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 Fees, Student Activity Fee and other non-instructional fees are not allowed.)
Amount of SUNY Assistance Requested for Each
Course ($ Total)
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 of Applicant Date
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 Ill approval.
If instruction will be given at another SUNY unit, forward 3 copies to instructing unit.
11. AUTHORIZATION BY APPLICANT’S SUPERVISOR (Chairman or Director) 12. VERIFICATION BY EMPLOYING UNIT’S PERSONNEL 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
PART III. INSTRUCTING CAMPUS (State-operated SUNY)
Date
Complete Part Ill and Forward 2 copies to employing campus
Application approved. Total Amount Waived $ _
(Itemize Charges Waived Below and Explain Amended Dollar Amounts #13)
Disapproved as submitted because
Authorized Signature Date
PART IV. Employing campus final action- Record disposition of application and distribute Affirmative Action Copy per internal procedures.
