ࡱ> %` bjbjNN .,, tttttttL'L'L'8'`(xH)000003z5OGQGQGQGQGQGQG$rIhKxuGt80088uGtt002HA?A?A?8pt0t0OGA?8OGA?A??tt?0) !C{L'k9X?@LHH0xH?RL9 RL?RLt?<V67|A?7d7V6V6V6uGuG>^V6V6V6xH8888"L'L'tttttt  APPLICATION (PUBLIC ACT 90-0282) Interinstitutional 50% Tuition Waiver for Children of Public University EmployeesAPPLICATION for 50% Tuition Waiver at (name of university/campus): FORMTEXT      Semester and year for which request is made: FORMCHECKBOX  Fall  FORMCHECKBOX  Spring  FORMCHECKBOX  Summer of (yr) FORMTEXT     Student Name: FORMTEXT      Birth Date: FORMTEXT   - FORMTEXT   - FORMTEXT     SSN#: FORMTEXT    - FORMTEXT   - FORMTEXT     Student's Campus Address: FORMTEXT      Phone: FORMTEXT    / FORMTEXT    - FORMTEXT     Student's Permanent Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT   Zip: FORMTEXT      Student Certification of Registration Compliance & Acknowledgement of PoliciesI certify that I am not required to be registered with the Selective Service because (CHECK ONE BELOW):  FORMCHECKBOX  A. I am female.  FORMCHECKBOX  B. I am a permanent resident of the trust territory of the Pacific Islands or the Northern Mariana Islands.  FORMCHECKBOX  C. I have not reached my 18th birthday.  FORMCHECKBOX  D. I am in the armed services on active duty (members of the Reserves and National Guard are not considered on active duty).  FORMCHECKBOX  E. I was born before 1960.  FORMCHECKBOX  I certify that I am registered with the Selective Service. I hereby declare that the Student Certification of Registration Compliance is true and correct and that I am a child or stepchild who is eligible for the 50% tuition waiver pursuant to P.A. 90-0282 and related policies/procedures. I request and understand that this information will be verified by accessing university records, and that total partial undergraduate tuition waiver benefits granted to me may not exceed the 4-year limitation established in P.A. 90-0282. In the event this application contains any false statements, errors or omissions pertaining to my parent's service record or in the event total partial undergraduate tuition waiver benefits among eligible institutions exceed the 4-year limitation, I will be responsible for the full value of any ineligible benefits that I may have received. I understand that a separate "Tuition Waiver Benefit Utilization Record" must be completed for each institution in which I have been enrolled while utilizing these tuition waiver benefits, that the tuition waiver benefit utilization record may be subject to verification by the tuition waiver granting institution, and that tuition waiver approval protocols shall be subject to individual university policies. (See attached policy statement for additional information.) PLEASE NOTE: To avoid being billed incorrectly the student should register for classes before completing/submitting this form. Tuition waivers at SIUE are due in the Office of Human Resources by the 10th day after the official start of the semester. Tuition waivers received after the deadline will not be processed. Student Signature:Date:Parent's Disclosure/Certification of Illinois Public University EmploymentInstructions: Please complete the following information as thoroughly as possible. All items must be completed. Percentage and dates of employment must be listed for each position claimed. The human resource or personnel office at listed universities may formally confirm the employment record and/or parent/child relationship through the use of University employment/benefit records at all locations for which employment credit is claimed. Confirmation procedures may require additional documentation. Qualified Employee (Parent) Name: FORMTEXT      SSN/ID#: FORMTEXT    - FORMTEXT   - FORMTEXT     Banner ID: FORMTEXT      Employing University: FORMTEXT      Work Phone: FORMTEXT    / FORMTEXT    - FORMTEXT     Employment Category: FORMCHECKBOX  Faculty FORMCHECKBOX  Administrative Professional FORMCHECKBOX  Civil Service I hereby declare that this student is my child or stepchild. Employee signature is not required as a condition of student eligibility.Employee Signature:Date: To be completed by Applicant/Parent (use additional sheet if necessary) Institution (branch or location, list current employer first)Inclusive Dates of EmploymentPercent of Employment FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FOR OFFICE USE ONLYApplicant Information Confirmed/CorrectedAuthorized University Signature & Printed NameDateAccount #:Amount:HR Initials:Date: TUITION WAIVER BENEFIT UTILIZATION RECORD Public Act 90-0282 Instructions: The following information must be completed by the student, certified by the department responsible for monitoring academic record(s), and attached to the Tuition Waiver Application in the event that you have (are) already accessed(ing) the 50% tuition waiver benefit at another Illinois public university. Student Name: FORMTEXT      Birth Date: FORMTEXT   / FORMTEXT   / FORMTEXT     Soc. Sec. No.: FORMTEXT    - FORMTEXT   - FORMTEXT     Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT   Zip: FORMTEXT       Local Phone: FORMTEXT    / FORMTEXT    - FORMTEXT     Application for 50% Tuition Waiver at (name of university): FORMTEXT      Major: FORMTEXT      Expected Date of Graduation: FORMTEXT      Name of Institution where previously/currently enrolled: FORMTEXT       Academic terms during which the 50% tuition waiver benefit was utilized at another Illinois Public University (specify total credit hours for which the 50% tuition waiver was applicable):Sem./YearHoursSem./Yet v    * , H J L b d ϽxfxxTxx#j hJ?hJ?OJQJU#jc hJ?hJ?OJQJUjhHOJQJU-jhJ?CJOJQJU]^JmHnHu(j/hHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^JhHOJQJhI5hI55OJQJhI5OJQJjhI5CJUhH5>*OJQJHt smm$Ifwkde$$IfTlx0 >+W S0+4 laT $$Ifa$gdI5$dxa$ͽ * b $Ifwkd$$IfTl0>+bH0+4 laT     0 2 4 H J L P ƴ{rٴ]{rH{(j hHCJOJQJU]^J(j hHCJOJQJU]^JhH6OJQJ-jhJ?CJOJQJU]^JmHnHu(j hHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^JhI5hHOJQJhI5OJQJhHOJQJjhHOJQJU#jO hJ?hJ?OJQJU  2 822) $$Ifa$$Ifkd9 $$IfTl4ֈ"W'>+/F0+4 laf4TP R T V j l n r t v x  ze(jhHCJOJQJU]^J(j]hHCJOJQJU]^JhHOJQJhH6OJQJ(j hHCJOJQJU]^J-jhJ?CJOJQJU]^JmHnHu(ju hHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^J"2   )kd$$IfTl4ֈdX #>+fjbrt0+4 laf4T $$Ifa$$If      J L ` b d n p r ٵv›fZGf%jWhHCJOJQJU^JhHCJOJQJ^JjhHCJOJQJU^J.jhphpCJOJQJU]^JhpCJOJQJ]^J"jhpCJOJQJU]^JhHOJQJhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(jEhHCJOJQJU]^J J r * R Okd$$IfTl4\2 J">+ p0+4 laf4T $$Ifa$$If ( * , @ B D N P λΨΠx`I-jhJ?CJOJQJU]^JmHnHu.jhphpCJOJQJU]^JhpCJOJQJ]^J"jhpCJOJQJU]^JhH6OJQJhHOJQJ%jChHCJOJQJU^J%jhHCJOJQJU^JhHCJOJQJ^JjhHCJOJQJU^J*jhJ?CJOJQJU^JmHnHuP R b d x z | ˳؜lWNNhH6OJQJ(j!hHCJOJQJU]^J(jhHCJOJQJU]^J"jhHCJOJQJU]^JhH6OJQJ-jhJ?CJOJQJU]^JmHnHu.jAhphpCJOJQJU]^JhpCJOJQJ]^J"jhpCJOJQJU]^JhHOJQJhHCJOJQJ]^JR T V b ~~~u~u~ $$Ifa$$Ifzkdq$$IfTl40@ >+ 0+4 laf4T % dx$Ifkd$$IfTl4֞@ <!6$&>+ vvv0+4 laf4T dx$If NO[\jkl()789WXfٷ٣ُلp\'jhJ?hJ?CJOJQJU'j[hJ?hJ?CJOJQJUhHCJH*OJQJ'jhJ?hJ?CJOJQJU'jshJ?hJ?CJOJQJU'jhJ?hJ?CJOJQJUjhHCJOJQJUhHCJOJQJhH5>*OJQJhHOJQJhH6OJQJ" N' $$Ifa$kd$$IfTl4֞@ <!6$&>+ vvv0+4 laf4TNO[(W|v|v|$If dx$If h$If^h & F$Ifekd]$$IfTl4>++0+4 laf4T fghy{   YZgBWXz{ӽӵӵӵӐӵ~qY~.j{ hphpCJOJQJU]^JhpCJOJQJ]^J"jhpCJOJQJU]^JhH6CJOJQJhH56CJOJQJhH5>*CJOJQJhHOJQJhHCJH*OJQJhH5CJOJQJhHCJOJQJjhHCJOJQJU'jChJ?hJ?CJOJQJU   $$Ifa$ekd$$IfTl4>++0+4 laf4T dx$If$If   `W dx$Ifkd[$$IfTl4\>+Hx0+4 laf4T YZV*$$Ifekd3$$IfTl4>++0+4 laf4T $$Ifa$ekd$$IfTl4>++0+4 laf4TVWXz$If $$Ifa$gkd$$IfTl4>++0+4 laf4T dx$If  "$8:<BDFH\^`dfhj~ɐɥ{ɥfɷN.j1#hHhHCJOJQJU]^J(j"hHCJOJQJU]^J(jE"hHCJOJQJU]^J(j!hHCJOJQJU]^J"jhHCJOJQJU]^JhHCJOJQJhHOJQJhHCJOJQJ]^J"jhpCJOJQJU]^J-jhJ?CJOJQJU]^JmHnHu"{u{u$If $$Ifa$zkd $$IfTl40 >+` J0+4 laf4T ":<PRTZ\^`tvx~¸ʠʸʋva¸(j3&hHCJOJQJU]^J(j%hHCJOJQJU]^J(jG%hHCJOJQJU]^J.j$hHhHCJOJQJU]^JhHCJOJQJhHOJQJhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J%":^UOC: $IfgdH $$Ifa$gdH$If $$Ifa$kd#$$IfTl4\ >+` $ :0+4 laf4T4U^UOOO$If $$Ifa$kd&$$IfTl4\ 3y#>+` ?F0+4 laf4T45CDEUVGH瘣pcNp(jG.hHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^JhH>*CJOJQJhH6CJOJQJhH5CJOJQJhHOJQJ'j(hJ?hJ?CJOJQJU'jm(hJ?hJ?CJOJQJU'j'hJ?hJ?CJOJQJUhHCJOJQJjhHCJOJQJUUVW^UO$If dx$IfkdY)$$IfTl4\ :.>+` F 0+4 laf4T $$Ifa$$Ifekd*$$IfTl4>++0+4 laf4TFG`TKT $$Ifa$ $dx$Ifa$kd5+$$IfTl4\l>+t0+4 laf4TGH $$Ifa$gkd,$$IfTl4>++0+4 laf4T6^sjaa $$Ifa$ $Ifgdpkd--$$IfTl4FdJ>+  0+    4 laf4T  $&(2468LNPZ\^`bvxzɴɟɗɂs^(j0hHCJOJQJU]^JhH>*CJOJQJ]^J(j[0hHCJOJQJU]^JhHOJQJ(j'/hHCJOJQJU]^J(j.hHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^J-jhJ?CJOJQJU]^JmHnHu"^`qhhh $$Ifa$kd/$$IfTl4FdJ>+  0+    4 laf4T&(*,@BDNPRT~ٳٞٳٞtٞٞ_ٳThH6CJOJQJ(jO3hHCJOJQJU]^J(j2hHCJOJQJU]^J(jo2hHCJOJQJU]^JhHCJOJQJ]^JhHOJQJhH>*CJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(j;1hHCJOJQJU]^J*Rqhhh $$Ifa$kd1$$IfTl4FdJ>+  0+    4 laf4TRTV~qe\ $$Ifa$ $dx$Ifa$kd3$$IfTl4FdJ>+  0+    4 laf4T~   $$Ifa$gkd4$$IfTl4>++0+4 laf4T  " # & ' ( ) O P Q R ~ !!!!" 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I request and understand that this information may be verified by means of accessing university records and that the total partial undergraduate tuition waiver benefit granted to me may not exceed the 4-year limitation established in P.A. 90-0282. A separate "Tuition Waiver Benefit Utilization Record" must be completed for each institution in which the student has been enrolled24 nf]]]]]] $$Ifa$kd_G$$IfTl4ֈp DD%*| X4 laf4TJLNXZ\^rtv~˜ĘΘИҘԘٵٵٵٵ|ٵgٵٵR(jIhHCJOJQJU]^J(j|IhHCJOJQJU]^JhH>*CJOJQJ]^J(jIhHCJOJQJU]^J(jHhHCJOJQJU]^JhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(j&HhHCJOJQJU]^J  "68:DFHJ^`bjlnpҽߦґߦ|ߦgߦ_hHOJQJ(jKhHCJOJQJU]^J(jHKhHCJOJQJU]^J(jJhHCJOJQJU]^J-jhJ?CJOJQJU]^JmHnHu(jhJhHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^JhH>*CJOJQJ]^J \Қd[[[[[[ $$Ifa$kd(L$$IfTl4ֈp DD%*| X4 laf4T™ؙ֙ڙ $&(2468LNPXZ\^rٵٵٵٵٵٵvٵٵaٵٵ(jNhHCJOJQJU]^J(jWNhHCJOJQJU]^J(jMhHCJOJQJU]^J(jwMhHCJOJQJU]^JhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(jMhHCJOJQJU]^J#rtvšĚƚΚКҚԚ "$ٵٵٵٵٵٵvٵnٵYٵ(jQhHCJOJQJU]^JhHOJQJ(jPhHCJOJQJU]^J(j#PhHCJOJQJU]^J(jOhHCJOJQJU]^JhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(jCOhHCJOJQJU]^J"Jr6^d[[[[[[ $$Ifa$kdQ$$IfTl4ֈp DD%*| X4 laf4T$&:<>FHJL`bdnprt›֛؛ڛva(j,ThHCJOJQJU]^J(jShHCJOJQJU]^J(j@ShHCJOJQJU]^J(jRhHCJOJQJU]^J-jhJ?CJOJQJU]^JmHnHu(j`RhHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^J% &(*2468LNPZ\^`bvxzٵٵٵٵٵٵnٵٵYٵ(j;WhHCJOJQJU]^J(jVhHCJOJQJU]^JhHOJQJ(jUhHCJOJQJU]^J(j UhHCJOJQJU]^JhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(jThHCJOJQJU]^J"^`֜$Ld[[[[[[ $$Ifa$kdU$$IfTl4ֈp DD%*| X4 laf4TĜƜȜҜԜ֜؜ "$&:<>HJLNbdfprtvva(jqYhHCJOJQJU]^J(jYhHCJOJQJU]^J(jXhHCJOJQJU]^J(jXhHCJOJQJU]^J-jhJ?CJOJQJU]^JmHnHu(jWhHCJOJQJU]^JhHCJOJQJ]^J"jhHCJOJQJU]^J%ĝƝDEFI\]deg{ͽνнѽӽԽֽ׽ٽ&'ٵٵٵ|x|x|x|xpfhg,SOJQJ^Jhg,SOJQJh1]jh1]UhH5OJQJUhH6OJQJhHOJQJ(j]ZhHCJOJQJU]^JhHCJOJQJ]^J-jhJ?CJOJQJU]^JmHnHu"jhHCJOJQJU]^J(jYhHCJOJQJU]^J%ĝƝCd[U$If $$Ifa$kdZ$$IfTl4ֈp DD%*| X4 laf4T while utilizing tuition waiver benefits pursuant to P.A. 90-0282.Student SignatureDateFOR OFFICE USE ONLY50% tuition waiver benefit utilization record confirmation (optional as requested by the tuition waiver granting institution): In accordance with institutional standards for tuition waiver benefit utilization, the record outlined above is correct. 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