APPLICATION FOR TUITION WAIVER BENEFIT

To Be Completed by Employee or Annuitant  (Please Print)

Name of  Employee or Annuitant:___________________________

Cost Center:___________________                         Bargaining Unit:_________________ 

Name of Employing University:  __________________________________________________ 

Name of Student:  ___________________________________________________________ 

Date of Birth:  _____________ Relationship of Student to Employee/Annuitant: _______________

Name of Attending University:  __________________________________________________ 

Semester/Year:  ________/________

Percentage of Tuition Waiver:     50% ______ 

                                                      100% ______ (applies to Office of the Chancellor Staff & Presidents only) 

Employee/Annuitant Verification: I hereby certify that the above-named student qualifies as my child or spouse (for Office of the Chancellor staff and Presidents only) in accordance with, and meets the qualifications as defined by the Board of Governor’s Policy.  I agree to provide to the university proof of relationship and age as may be required.  I understand it is my responsibility to meet the deadlines for tuition payment at the university attended by the student.

____________________________________      ___________________________
Employee/Annuitant Signature                                                            Date
(Guardian or Beneficiary may provide verification of relationship in the event of Employee/Annuitant death)

 *****************Return to Employing University’s Human Resources Department*********************** 

University Use Only

HUMAN RESOURCES DEPARTMENT at employing university: The employee’s/annuitant’s eligibility and student’s qualifications for the tuition waiver have been reviewed, and I hereby certify that the information submitted is true and accurate to the best of my knowledge.

_______________________________________      _____________________________
Signature and Title                                                                                  Date

FORWARD TO BUSINESS OFFICE at university attended by student.
BUSINESS OFFICE must forward copies to other appropriate offices at attending university.
HR2004