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 employee. To avoid being incorrectly billed, employees should register BEFORE completing this form. Completed forms are to be submitted to the Office of Human Resources. Please note the application is good for one academic year. The application deadline for tuition waivers for each academic year is August 31. (Example: The deadline for Fall 2013, Spring 2014, and Summer 2014 waivers would be August 31, 2013). Applications submitted 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. This is in accordance to the Civil Service Statues as defined in Section 36e.

Application for Tuition Waiver at:	Southern Illinois University Edwardsville

Last
Name:	First
Name:	MI:	Email Address

(Univ Employed):
Univ ID Number at Employing Univ:	Campus Phone:
Department:	Title:
1. Job Classification: Civil Service Faculty Admin/Professional Staff

Job Status: Active Retiree Dependent/Spouse of Deceased
2. Employment Status: Full-Time OR Part-Time &	Percent
3. Place of Employment:

Chicago State University

Southern Illinois University-Carbondale

Eastern Illinois University

Southern Illinois University-School of Medicine

Governor State University

University of Illinois-Chicago

Illinois State University

University of Illinois-Springfield

Northeastern Illinois University

University of Illinois-Urbana/Champaign

Northern Illinois University

Western Illinois University

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 (Banner ID):
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:
WHEN COMPLETED PLEASE RETURN A COPY TO REQUESTING INSTITUTION 11/2013 – previous version obsolete

REQUEST FOR INTERINSTITUTIONAL WAIVER OF TUITION

Joyree Chura

2013-11-26

SIUE