Graduate Fee Waiver Application for Prospective & Current USI CAP Instructors (Rev. 11/2015)

Return this form to:
CAP Office, USI Outreach & Engagement, 8600 University Boulevard, Evansville, IN 47712 or

·  A new application must be completed and approved prior to each semester or summer term
in which the participant enrolls.

·  Past recipients of a CAP Graduate Fee Waiver are not guaranteed future CAP Graduate Fee Waivers.

Participant Information

First Name: ______M.I.: ______Last Name: ______

Participant Status (check one)

___ Prospective USI CAP Instructor for the following USI CAP course(s): ______

___ Current USI CAP Instructor for the following USI CAP course(s): ______

Home Address: ______

City: ______State: ______Zip: ______

Home Phone: (______) ______Cell Number: (______) ______

Affiliated High School: ______

Work Email: ______Personal Email: ______

CAP Graduate Course Information for Upcoming Term

Course # / Course Name / 5-Digit CRN / Start Date / End Date / # of Credit Hours

Example:

ENG 600.301 / The History of Literature / 45678 / 6/13/16 / 7/15/16 / 3

Principal Endorsement

As principal of the previously named high school, I endorse this application and agree to the listed terms to offer the USI CAP course, taught by this instructor, for the required number of years. [1 course=1 year; 2-3 courses=2 years; 4-6 courses=3 years]

Principal Signature: ______Date: ______

Participant Endorsement

I am receiving other funding or reimbursement for the course(s) listed above. ____Yes ____No

If “Yes,” indicate the type and amount.


As a prospective USI CAP instructor, I agree to teach the USI CAP course(s) for the required number of years, once approved as a USI CAP instructor. [1 course=1 year; 2-3 courses=2 years; 4-6 courses=3 years]
______Yes _____No (If “No,” please explain.)


As a current USI CAP instructor, I agree to continue teaching the USI CAP course(s) within the next 12 months. _____Yes _____No (If “No,” please explain.)

Please initial to indicate agreement with the following statements:

I understand that the graduate course(s) listed above must be approved by the department chair and/or faculty liaison before CAP awards a CAP Graduate Fee Waiver. ______Yes

I understand that I cannot prepay for a graduate course and be reimbursed. Once I have received approval to take the course, I will enroll in the course and the CAP Graduate Fee Waiver will be applied to my student account. The cost of textbooks associated with the course, or any fines accrued, will be my responsibility as the recipient of the CAP Graduate Fee Waiver. ______Yes

I understand that failure to complete the graduate course will require repayment of 100% of the CAP Graduate Fee Waiver. ______Yes

I understand that withdrawing from the course after the 100% refund period will result in my being fully responsible for whatever amount of tuition, fees and fines are owed at that time, whether a portion or the entire amount. ______Yes

I grant permission for the USI CAP Office to review my academic records while participating in the CAP Graduate Fee Waiver program to verify that final course grades meet or exceed requirements of the CAP Graduate Fee Waiver program and the office of USI Graduate Studies. ______Yes

I understand that receiving future CAP Graduate Fee Waivers is partially dependent upon my successful performance in the coursework. ______Yes

I understand the CAP Graduate Fee Waiver will not cover repeated courses, regardless of reason. ______Yes

I understand the CAP Graduate Fee Waiver may be considered taxable income. ______Yes

Participant Signature: ______Date: ______

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