ࡱ> pro'` Cbjbj ^ 4T&0 #&%&%&%&%&%&%&$(h*I&]sssI&&!!!s #&!s#&!!! QuB}!"t&0&!++!+!h!Tg I&I&q!:&ssss  APPLICATION FOR TUITION AND FEE WAIVER SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE  PLEASE NOTE: No tuition and fee waiver request form will be approved or processed after the last official day to withdraw from classes and receive a full refund. Incomplete forms will not be processed and will be returned to the employee. To avoid being incorrectly billed, employees should register BEFORE completing this form. Tuition and fee waiver request forms are due in the Office of Human Resources by the 10th day after the official start of the semester. Forms received after the deadline will not be processed.NAME: (Last)  FORMTEXT      (First)  FORMTEXT      (Middle)  FORMTEXT   SSN:  FORMTEXT      Banner ID: FORMTEXT      Phone Ext: FORMTEXT      Department:  FORMTEXT      Class/Rank/Title: FORMTEXT      1. Job Classification:  FORMCHECKBOX  Civil Service  FORMCHECKBOX  Faculty  FORMCHECKBOX  Admin/Professional Staff  FORMCHECKBOX  Retiree  FORMCHECKBOX  Dependent/Spouse of Deceased2. Are you an Out of State Resident  FORMCHECKBOX  Yes  FORMCHECKBOX  No3. Employment Status:  FORMCHECKBOX  Full-Time OR  FORMCHECKBOX  Part-Time &  FORMTEXT    Percent4. What Semester are you registering for?  FORMCHECKBOX  Fall  FORMCHECKBOX  Spring  FORMCHECKBOX  Summer of (yr)  FORMTEXT     5. No. of hours registered for:  FORMTEXT    FORMCHECKBOX  Undergraduate  FORMCHECKBOX  Graduate STATEMENT OF DRAFT COMPLIANCE  FORMCHECKBOX  I certify that I am registered with the Selective Service.  FORMCHECKBOX  I certify that I am not required to register with the Selective Service because:  FORMCHECKBOX  I am female.  FORMCHECKBOX  I am in the Armed Services on active duty. (NOTE: Does not apply to members of the Reserves and National Guard who are not on active duty.)  FORMCHECKBOX  I have not reached my 18th birthday.  FORMCHECKBOX  I was born before 1960.  FORMCHECKBOX  I am a citizen of the Federated States of Micronesia, or the Marshall Islands or a permanent resident of the Trust Territory of the Pacific Islands (Palau).  FORMCHECKBOX  I am an international student (applicable only to State of Illinois funded programs).  FORMCHECKBOX  I am an incarcerated student. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING COMPLIANCE STATEMENT IS TRUE AND CORRECT. EMPLOYEE SIGNATURE:DATE: FOR CIVIL SERVICE ONLY: Approval of UVWXYg      ( ƼƱƤ蓁iRCh\V5CJOJQJ]^J-jh WCJOJQJU]^JmHnHu.jh\VhhJCJOJQJU]^J"jh\VCJOJQJU]^Jh\V6OJQJh\VOJQJh\VCJOJQJ]^Jh\VCJH*OJQJh5vNCJOJQJh\VCJOJQJh\VCJOJQJ^Jh CJOJQJ^Jh\V5OJQJh\Vjh\VCJU*TUVWYXSSgd#o{kde$$Ifl X0 &  t0 $44 la$d$Ifa$gd\V$d$@&Ifa$gd\V $$Ifa$gd+yQCY  * R f $d$Ifa$gdhJdkd$$IfTl$$$04 laT d$IfgdhJ( * , @ B D N P R d f h | ~ ׿䙑|s[s.j h\VhhJCJOJQJU]^Jh\V5OJQJ(jw h\VCJOJQJU]^Jh\VOJQJh\V5CJOJQJ]^J-jh WCJOJQJU]^JmHnHu.j h\VhhJCJOJQJU]^Jh\VCJOJQJ]^J"jh\VCJOJQJU]^Jh\V6OJQJ ;//// d$IfgdhJkd $$IfTlֈ4!$$ * @04 laT    * , . 8 : < T V X Z n p r | ~ ֶֿֿ֞wof֞Nֿwf֞.j h\VhhJCJOJQJU]^Jh\V6OJQJh\VOJQJh\V5CJOJQJ]^J.j h.Hh\VCJOJQJU]^Jh\VCJOJQJ]^Jh\V56OJQJh\V5OJQJ-jh WCJOJQJU]^JmHnHu"jh\VCJOJQJU]^J.j h.Hh\VCJOJQJU]^J  < > X ,kdk $$IfTl4ֈH z$$*04 laf4T d$IfgdhJX `Ckd$$IfTl4\4:$$ d 04 laf4T$d$Ifa$gdhJ d$IfgdhJ   " D F b d f | ~ 12@ְֿo]K#jh Wh WOJQJU#jch Wh WOJQJU#jh Wh WOJQJU#j{h Wh WOJQJUjh\VOJQJUh\VOJQJh\V5OJQJh\V5CJOJQJ]^J-jh WCJOJQJU]^JmHnHu"jh\VCJOJQJU]^J.j h\VhhJCJOJQJU]^J@ABae پ٬ٚوzp_z!jh\VCJOJQJUh\VCJOJQJjh\VCJOJQJU#jUh Wh WOJQJU#jh Wh WOJQJU#jh Wh WOJQJU#j\h Wh WOJQJUh\V5OJQJh\VOJQJjh\VOJQJU#jKh Wh WOJQJU`a -bkdD$$IfTx$$$04 xaT d$IfgdhJbkd$$IfTx$$$04 xaT $tv&(*,@̷̷̷̥̓́ygZh\VCJOJQJ]^J"jh\VCJOJQJU]^JhhJOJQJ#j"h Wh WOJQJU#jh Wh WOJQJU#j6h Wh WOJQJUjh\VOJQJUh\V5OJQJh\VOJQJh\VCJOJQJjh\VCJOJQJU&jh WCJOJQJUmHnHu *PRhkd?$$IfTxFn$$* 0    4 xaT d$IfgdhJ@BDLNPT\<=KLMٵٵٵq_M#jZh Wh WOJQJU#jh Wh WOJQJU#jwh Wh WOJQJUjh\VOJQJU(jh\VCJOJQJU]^Jh\V5OJQJh\VOJQJh\VCJOJQJ]^J-jh WCJOJQJU]^JmHnHu"jh\VCJOJQJU]^J(jh\VCJOJQJU]^JRTthhh d$IfgdhJkd $$IfTxF"$$0    4 xaT< ptffZZJJJd$If`gdhJ d$IfgdhJ d$@&IfgdhJkdc$$IfTxF. $$ r0    4 xaTM   +,:n#jh Wh WOJQJU#jh Wh WOJQJU#jh Wh WOJQJU#j2h Wh WOJQJU#jh Wh WOJQJU#jFh Wh WOJQJU#jh Wh WOJQJUjh\VOJQJUh\VOJQJ&~+[~pp d$@&IfgdhJdkd$$IfTxe$$$04 xaT d$IfgdhJd$If`gdhJ :;<[@AAAAAAAAAAAAAAAAAAAAB BBBCBFBGBOBUBBBBBBBBBBBBBBBBٽٽٽٽٽٽٽٽٽٽٽٲٝٝh\V5>*CJOJQJh\VCJOJQJh5vN5CJOJQJh\V5CJOJQJh\V>*OJQJh5vNOJQJUh\V5OJQJh\VOJQJjh\VOJQJU#j h Wh WOJQJU8AB33$d$Ifa$gdhJkd $$IfTx\ L$$ ,T04 xaT d$@&IfgdhJ$d$@&Ifa$gdhJthis application by the supervisor and the departmental executive officer or fiscal officer certifies that the employee's course work attendance is in compliance with University Policy and that schedules for make-up time (if required) for courses taken during basic work hours will be maintained at the employing department. Please refer to the appropriate union contract or contact The Office of Human Resources for assistance. ApproveDisapproveDATE:Signature of Immediate SupervisorApproveDisapproveDATE:Signature of Dept. Exec. 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