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 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 academic year. The application deadline for tuition waivers for each academic year is the last business day of August (Example: The deadline for Fall 2014, Spring 2015, and Summer 2015 waivers 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.

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 Dependent/Spouse of Deceased
2. Are you an Out of State Resident Yes No
3. Employment Status: Full-Time OR Part-Time &	Percent
4. What Semester are you registering for? Fall Spring Summer	- yr
5. Program of Study:

Undergraduate Graduate

STATEMENT OF DRAFT COMPLIANCE

I certify that I am registered with the Selective Service.

I certify that I am not required to register with the Selective Service because:

I am female.

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.)

I have not reached my 18th birthday.

I was born before 1960.

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).

I am an international student (applicable only to State of Illinois funded programs).

I am an incarcerated student.

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING COMPLIANCE STATEMENT 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:
Approval of this 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.

I plan on taking classes during my normal work hours: Yes No

**If employee plans to take classes during their normal work hours the immediate supervisor and department executive officer/fiscal officer must sign to approve the hours away from work. Employee must present class schedule to supervisor for approval for each semester to take classes during scheduled work hours.

**If employee is not taking classes during normal work hours (i.e. before/after work) signatures are not required

Approve
Disapprove
DATE:
Signature of Immediate Supervisor
Approve
Disapprove
DATE:
Signature of Dept. Exec. Officer/Fiscal Officer
FOR HUMAN RESOURCES OFFICE USE ONLY
Approve
Disapprove
DATE:
Signature of Authorized HR Personnel

6/24/2014 – previous versions obsolete

FACULTY APPOINTMENT APPROVAL FORM

lscrogg

2014-07-23

Joyree Chura

SIUE