CALIFORNIASTATEUNIVERSITY,EASTBAY

TUITION FEEWAIVERAPPLICATION(SELF)

INSTRUCTIONS:Pleaserevieweligibilitycriteriaonthefollowingwebsitebeforecompletingthisform:

This applicationistobecompletedbyeligibleemployees requestingadmissiontothe Tuition FeeWaiverProgram.Eligibleemployeesmustobtainauthorizationfromtheirimmediate supervisorandthe Office of HumanResourcesoriffaculty,fromthe VicePresident,AcademicAffairs.

TERM APPLYING FOR: □ Quarter □SemesterCampus to Attend: Due Date:

□ F 20___□W 20___□ S 20___□ SUM 20___ □ NEW or □ CONTINUING

□ Career Development*□ Work Related

(*Note: An“IndividualCareerDevelopmentPlan”mustbesubmittedoralreadyonfileinHR.)

Nameof Employee: Classification:

Department:

Department ID: (Required)
PS ID: BargainingUnit/MPP:

WorkNo.:

Class Standing: Freshman SophmoreJuniorSeniorGraduateDoctorate

DeclaredMajor:

Please list all course(s) for which you are applying for the Fee Waiver Program in the table below:

DEPARTMENT / COURSE-SECTION # / TITLE / UNITS / DAYS / TIME
-
- -
-

Employeerequestswaiveroffeesforonecourseduringregularlyscheduled working hours. *

Employeerequestswaiveroffeesfor______course(s)onowntime.

Employeerequestswaiveroffeesforonecourseduringregularlyscheduledworkinghoursandonecourseonowntime.

Online and off campus courses do not qualify for release time. Ifmorethanonecourseisbeingtakenduring

regularly scheduled workinghours,employee'sschedulewillbeadjustedasfollows:

REQUIRED: Describe how the content of the course(s) listed above relates to either your employment (if “Work Related”) or your degree objective (if “Career Development”). Attach additional page(s) if needed.

□ Proof of payment received and verified ______(HR initials)

I herebyauthorize the Office of HumanResourcesto reviewmygradesfor evaluationof progressinthisprogram. Iunderstandthat if Ichangecourses, thiswillrequire metosubmit anew Tuition Fee Waiverapplication.

Employee’s Signature

Date

Approval–AppropriateMPPAdministrator’sSignatureDate

*Approval–VicePresident,AcademicAffairs

(VPsignaturefor Faculty/R03 Only)
Date

Approvedfor unitsDeniedforreasonof:

Approval–HumanResourcesOffice Date

Rev June 2017S:\TrainingDevelopment\Fee Waiver\FeeWaiverEmployee Self 6-2017.doc