Section A: Employee Data
 Last Name:  First Name:

Middle Name:
Employee #: Org Unit: Faculty  Staff   
Office of Human Resources Form

Tuition Waiver Form

     Application for Tuition Waiver Instructions

Tuition Waiver is independent of the admission and registration processes.

ONE FORM TO BE COMPLETED BY EMPLOYEE FOR EACH PERSON USING WAIVER FOR EACH TERM OF ENROLLMENT.

Employee Enrollment (Sections A, B, C, & E)  Spouse/Dependent Enrollment (Sections A, B, D, & E)

 

Approval Signatures:

 

         Date

Employee:

 

 Department Head:

 

 VP (Applicable to Section C2):

 

Student Financial Aid:  

Human Resources:

 

Please Return All Copies of Completed Form to Human Resources

Section B: Course(s) for Tuition Waiver - Please choose semester and provide required class detail

Academic Year

 

 

 

            Semester:

Fall           Spring/Winter            Summer          

Section C: Employee Enrollment Information

C1

C2

Enrollment in the selected course(s) will not be scheduled during regular working hours.

Enrollment in the selected course(s) will be scheduled during regular working hours. 

Office of Human Resources Form

Please attach a memo requesting exception to policy stating reasons, adjusted work schedule and VP's approval
List only courses eligible to be waived. Possible three (3) to six (6) credit hours depending on eligibility

Course Title

(Ex) College Writing

Location

(Ex) NKU, Gateway Other

Course # - Section

(Ex) Eng 101-001

Days

(Ex) M

Times

(Ex)

6:15-9:00pm

Credit Hrs

(Ex) 3

Course Classification

(Ex) Undgr, Grad, Law

Section E: Verification of Information for this Tuition Waiver

I certify that all information provided for myself, spouse, and/or eligible dependent(s) on this form is true and accurate. I also certify that I have read and understand the conditions for participation and eligibility in the tuition waiver policy and agree to comply with policies, procedures and conditions set forth in the Request for Tuition Waiver Policy. I acknowledge and agree to a possible tax liability from this waiver which will be deducted from my pay check.

Note:

Person using this tuition waiver IS     IS NOT    receiving tuition assistance from another source.

A residual check will not be issued for any amount exceeding the total sum of tuition and mandatory class fees from the

tuition waiver, nor will there be a refund issued for withdrawing or dropping hours.
Section D: Spouse/Dependent Enrollment Information  

Relationship to Employee:

Spouse     Dependent

 Last Name:
 
 First Name:

I certify that my spouse or dependent meets dependent meets the criteria for eligibility to participate in the tuition

waiver program as outlined in the tuition waiver policy.
Middle Name:
Dependent DOB:


Dependent SSN:
 :