Tuition Waiver Request Form
Student’s Name _______________________________________________________ Student ID# ____________________________
Relationship to employee ______________________________________________________________________________________________________
Employee’s Name __________________________________________________ ID# ______________________________
Position Title _____________________________________________________ Department _______________________________________________
School Term/Semester (check one) Fall Spring Summer 20 __________
Course Code# (e.g., BIOL 111) Course Title Credit Hours
I certify that I am eligible for a Full Half waiver of tuition and fees because I am a:
FT Faculty Member FT Administrator FT Support Staff Member
Spouse of Spouse of Spouse of
Dependent of Dependent of Dependent of
FT Managerial Staff Adjunct Faculty Member PT Benefitted Support Staff Member
Spouse of Spouse of Spouse of
Dependent of Dependent of Dependent of
Sign as appropriate below. Spouses and dependent children’s forms must also have the employee’s signature
below.
I have read and understand the conditions (listed on reverse) and do hereby authorize payroll deductions if
conditions are not met, with regard to me and/or my dependents.
_________________________________________________________________ Date __________________________________________
Employee’s signature
_________________________________________________________________ Date __________________________________________
Spouse/dependent’s signature
_________________________________________________________________ Date __________________________________________
Supervisor/Dean’s Signature
HR Verification ____________ -over-
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Administrators/Full-Time Faculty/Managerial Staff/Retired Faculty Member
If I am an administrator, or faculty member, I understand that I am responsible for all tuition and
fees not covered by this waiver. I understand that I must remain employed through the whole
semester and must receive a grade of A,B,C, or I by the time of final grade submission in order to
keep this waiver in force. I hereby authorize payroll deductions if these conditions are not met,
with regard to me and/or my dependents. See Board/Union Agreement (for faculty members).
Support Staff
If I am a support staff member, I understand that I am responsible for all tuition and fees not
covered by this waiver. As a support staff member, I understand that I must remain employed
through the whole semester and must receive a grade of A,B,C, or I by the time of final grade
submission in order to keep this waiver in force. I hereby authorize payroll deductions if these
conditions are not met, with regard to me and/or my dependents. See Board/Union Agreement.
Adjunct Faculty
If I am an adjunct faculty member, I understand I am responsible for all tuition and fees not
covered by the waiver. I certify that I am teaching a course in the semester in which I am requesting
a tuition waiver. I understand that I must receive a grade or A, B or C by the time of final grade
submission in order to keep this waiver in force. I hereby authorize payroll deductions if these
conditions are not met, with regard to me and/or my dependents. See Board/Union Agreement.
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