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EMPLOYEE/DEPENDENT REQUEST FOR FEE WAIVER Print Form

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EMPLOYEE/DEPENDENT REQUEST FOR FEE WAIVER Print Form
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EMPLOYEE/DEPENDENT REQUEST FOR FEE WAIVER
Full-time employees who have been employed for at least six months may have tuition fees waived for two courses (8 credits or 240 clock
hours max). The employee must pay all other course fees; such as, but not limited to application, registration, and special fees. This waiver is
not applicable to avocational courses. Enrollment of courses is only on a "space available" basis, as determined one day prior to the end of add/
drop period.
Spouses and dependent children (as claimed on the most recent federal income tax return) of eligible employees may receive the same benefit
as employees, under the same terms and conditions, as outlined above.
Employee
Spouse or Dependent
Last Name:
MI:
First Name:
Student ID:
I'm requesting a waiver for:
Fall
Spring
Year
Summer
Name of Courses: List the course number and reference number
Course ID
Reference Number
Note: Employees may not register for course(s) that conflict with their scheduled work hours unless the course(s) is approved by
their Supervisor.
Supervisor's Signature
Title
Date
Statement of Certification and Agreement
I certify that I am an eligible full-time employee and that the above-named person, if applicable, is my legal spouse or dependent
(as claimed on the most recent federal income tax return) for purposes of this agreement.
In the event that my spouse, dependent, or I failed to successfully complete, withdraws from, or fail to meet requirements for the
waived course(s), I will be required to reimburse the College for any fees waived. Reimbursement will also be required due to
changes in my employment status, as outlined in the Board policy (6Hx-18-5.76). I understand that the College reserves the right
to deduct any debts owed to the College from my paycheck.
Employee's Signature
Date
Employee Name (please print):
FOR OFFICE USE ONLY
Registration Office:
Cashier's Office:
Customer Number: 28 Contract:
Signature (Registration Rep.)
Registration Rep. Name (Printed)
Date
Receipt Number:
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