REQUEST FOR INTERINSTITUTIONAL WAIVER OF TUITION

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 student. To avoid being incorrectly billed, students should register BEFORE completing the form. Completed forms are to be submitted to the Office of Human Resources. Please note the application is good for one semester. The application deadline for tuition waivers for the Fall semester is the last business day of August (Example: The deadline for Fall 2014, would be August 29, 2014). Applications summited for Spring or Summer semesters are due by the 10th day after the start of the semester. Forms received after the deadline will not be processed.

Civil Service employees are limited to a maximum of two courses provided that the employee meets the conditions for admission as prescribed by the Office of Admissions.

Faculty, Administrative/Professional Staff Employees, and Retirees can only utilize the waiver at Universities in the SIU System.

Application for Tuition Waiver at (please select the school you will be attending):
Chicago State University
Southern Illinois University-Carbondale
Eastern Illinois University
University of Illinois-Chicago
Governor State University
University of Illinois-Springfield
Illinois State University
University of Illinois-Urbana/Champaign
Northeastern Illinois University
Western Illinois University
Northern Illinois University

NAME: (Last)	(First)	(Middle)
Banner ID Number:	Phone Ext	Campus Email
Department:	Title:
1. Job Classification: Civil Service Faculty Admin/Professional Staff

Job Status: Active Retiree
2. Employment Status: Full-Time OR Part-Time &	Percent
3. Place of Employment	Southern Illinois University Edwardsville	Effective Date of Employment:

/ /
4. What Semester are you registering for? Fall Spring Summer	(year)
5. Program of Study:

Undergraduate Graduate

STUDENT ID NUMBER AT UNIVERSITY STUDENT IS ATTENDING:
Course(s) (Civil Service Employees are limited to two classes a semester)
1.	CREDIT HOURS: GRAD UGRAD
2.	CREDIT HOURS: GRAD UGRAD
3.	CREDIT HOURS: GRAD UGRAD
4.	CREDIT HOURS: GRAD UGRAD

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT. I further declare that the application of this waiver serves as both official notification (unless denied) and my acceptance of this waiver. As a recipient of a tuition waiver award from Southern Illinois University, I understand that the University has the legal authority to release my name and address, the name of my former high school or college, the name of my award, and the award amount. This release is valid for the period of time the tuition waiver is in effect. The refusal to accept this agreement will result in a forfeit of the waiver. I also understand that the value of the tuition waiver for graduate course work over $5, 250 annually may be reported as taxable wages on Form W-2 and subject to tax withholding.

Employee Signature:
Date:

For Human Resources Office Use Only

Applicant Information Confirmed/Corrected	Authorized University Signature	Authorized University Printed Name	Title

Date

Reciprocal Institution

APPROVAL GRANTED BY:
RECIPROCAL INSTITUTION:
06/24/2014 – previous version obsolete

REQUEST FOR INTERINSTITUTIONAL WAIVER OF TUITION

lscrogg

2014-06-24

SIUE