Tuition Waiver Request Form - Dixie State University
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1STAFF
:
T
W
R
F
Complete A and E
Complete A, C, and E
UITION
AIVER
EQUEST
ORM
80
A. EMPLOYEE INFORMATION:
Full Given Name: _______________________________ DSU Id #:_______________________
Employee’s Department: ________________________ Semester: ______________________
FACULTY
STAFF
RETIRED
ADJUNCT
:
:
:
:
Complete A, B, and E
Complete A, C, and E
Complete A and E
Complete A, B, and E
(3 credit limit per Academic calendar year;
nontransferable)
Please note tuition waivers for the spring semester will be applied January 1 due to the 1098-T form.
B. Full Time FACULTY and Part Time ADJUNCT
CREDIT HOURS REQUESTED
: ______________
C: STAFF EMPLOYEES
Staff may take up to a 4 credit class during the regular work day if working towards a certificate or
degree or if required by the supervisor as job training. Exceptions to policy must be justified and approved by supervisor and vice-
president. Complete the following information for required classes and obtain supervisor's (and vice-president's) signature(s):
C
REDIT HOURS REQUESTED
: ______________
.
CLASS
TIME/DAYS
JUSTIFICATION
Supervisor’s Signature: __________________________________ Date: _______________
Vice-President Signature: _________________________________ Date: _______________
:
D: LEGAL SPOUSE AND/OR LEGAL DEPENDENT STUDENT(S)
Instructions for DEPENDENT(S)
of eligible faculty, staff, & retirees
SPOUSE NAME
DSU ID #
CREDITS
Complete A, D, and E
DEPENDENT NAME
DSU ID #
BIRTHDATE
MARRIED? YES OR NO
CREDITS
E: AUTHORIZED SIGNATURES
Return form to the Human Resources Department with employee’s signature for authorization.
Employee Signature: ______________________________________ Date: ______________________
Human Resources Office: _________________________________ Date: ______________________
Policy 344 Compensation and Benefits - Tuition Waiver
Questions or concerns, contact the Human Resources Department at 435-652-7520
Last Updated: 12/2015
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