This form must be completed for each course being taken.
To be completed by SCUPA Member (Please Print) and returned to Lock Haven University's
Human Resources Department when completed.
Name of Employee:
_____________________________
SAP ID:
________________________
Bargaining Unit
:
SCUPA
Name of Employing University
:
Lock Haven University of Pennsylvania
Cost Center
:____________________________________________________________________
Name of attending University:
_____________________________________________________
Semester/Year:
_________________________________________________________________
Course Level to be taken: Undergraduate Graduate
Toatl Credit Hours Enrolled
(Please reference applicable tuition waiver policy for employee waiver limits)
**Not to exceed 128 undergraduate credits
**Not to ecveed 60 graduate credits or any combination of undergraduate or graduate credits up to 60 credits
**Undergraduate and/or graduate credits shall be limited to a maximum of 6 credits per semester and must be taken
during non-working hours
Employee Signature
Date
** Shall be on a "space available" basis as certified by the appropriate management authority.
UNIVERSITY USE ONLY
Date
HR2013
**Per CBA
APPLICATION FOR TUITION WAIVER BENEFIT
SCUPA Bargaining Unit
MEMBER ONLY
HUMAN RESOURCES DEPARTMENT at Lock Haven University: the employee's
eligibility for the tuition waiver has been reviewed, and I hereby certify that the
information submitted is true and accurate to the best of my knowledge.
Signature and Title
FORWARD TO BUSINESS OFFICE at university attended by student if other than home
University.
BUSINESS OFFICE must forward copies to other appropriate offices at attending
university.
