Employee And/or Dependent Tuition Waiver Form

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EMPLOYEE AND/OR DEPENDENT TUITION WAIVER FORM
Employee’s Name
Employee ID # & Position/Title
Phone #
Email
Dependent’s Name
Dependent’s Student ID or SS#
Phone #
Email
Relationship to employee: (check one)
( ) Self
( ) Spouse
( ) Unmarried Natural or Adopted Child
( ) Unmarried Step-Child
( ) Legal Ward
Does the dependent live with you? ( ) Yes
( ) No
( ) Yes ( ) No With Former Spouse
(Dependents must reside in the household of the employee or the employee’s former spouse. Exception: step-child must reside in the household of the employee)
Institution to Attend:
Term/Year
Course#
Course Name
Credit Hours online ( )Yes ( )No Audit: ( )Yes ( )No
Course#
Course Name
Credit Hours online ( )Yes ( )No Audit: ( )Yes ( )No
Course#
Course Name
Credit Hours online ( )Yes ( )No Audit: ( )Yes ( )No
Course#
Course Name
Credit Hours online ( )Yes ( )No Audit: ( )Yes ( )No
Course#
Course Name
Credit Hours online ( )Yes ( )No Audit: ( )Yes ( )No
I certify that I am familiar with the provisions of the Employee and/or Dependent Tuition Waiver policy and that the persons(s) requesting the tuition waiver benefits
qualifies as an eligible employee or dependent in accordance with the policy. (See reverse of form for policy and/or processing step.)
INITIAL BY
All fees (other than portion of tuition waiver), books and supplies are the responsibility of the student
EACH ITEM
Maximum of one audit per term
AND SIGN
Waiver does not apply to repeated courses
BELOW
Student must abide by the academic limitations and policies of the attending institution (including any
course limitations)
_________Unofficial transcripts and current course schedule must be attached to this form
It is the responsibility of the employee/ and or dependent to ensure that all documents and forms (requested by the college where the student is enrolled) are submitted and
signed by the appropriate personnel in a timely manner prior to submission. Any packets deemed as incomplete will cause a delay in the processing of the tuition waiver.
Please be sure to check with the college in which you are registered for courses to ensure the packet is complete.
Employee Signature
Date
Supervisor Signature
Date
(If required)
This section to be completed by the Human Resources department at the institution of employment.
Certification:
Full Waiver
2/3 Waiver
1/3Waiver
Full-Time Employment Date
or Date of Employee Retirement
*Dependents are eligible for waiver for a maximum of 5 years from date of employee retirement.
Certifier Name:
Title:
Date
This section to be completed by the appropriate college official at the institution of attendance.
Certification:
Student’s GPA is at least 2.0? ( )Yes ( )No
Certifier Name:
Title:
Department/Division
Date
This section to be completed by the President at the institution of attendance.
Based on the certified information above, I hereby certify that
______ has been approved to receive all benefits granted under
the Employee and Dependent Tuition Waiver Program for
____hours at the institution of
______.
President:
________
Date__
__
Notes:
Revised 3-25-2016

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