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Tuition-waiver - tuitionWaverForm

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U.S.A. forms for State University of New York College of Agriculture and Technology at Cobleskill

BROWSE STATE UNIVERSITY OF NEW YORK COLLEGE OF AGRICULTURE AND TECHNOLOGY AT COBLESKILL FORMS

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STATE UNIVERSITY OF NEW YORK
B-140W APPLICATION FOR TUITION AND FEE ASSISTANCE
PART 1 APPLICATION: Please complete PART 1 ONLY. Forward to the Human Resources Office.
Disclosure of Social Security number 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 Name____________________________________________ 2. Social Security Number ______________________________________
3. Campus Where Employed _____________________________________ 4. Payroll Title ______________________________________________
5. Present Employment Status (Check one) Research Foundation Employee University Employee (State Payroll)
A. To be completed by University employees on State Payroll only.
Negotiating Unit: (Check one) 01 NYSCOPBA 02 Administration 03 Operational 04 Institutional
05 PEF 08 UUP 13 M/C Other _________________________________________________________________
6. Highest Degree Earned _______________ 7. Campus Where Course(s) Will Be Held__________________________________________________
8. PLEASE DESCRIBE PROPOSED EDUCATIONAL PROGRAM (reasons 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 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 of Applicant Date
PART II. To be completed by Human Resources
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 (Chairman or Director)
________________________________________________________________________________ __________________________________
Authorized Signature Date
12. 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
PART III. INSTRUCTING CAMPUS (State-operated SUNY)
Complete Part III 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
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Completed 15 November 2019

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