Staff/Faculty Fee Waiver Application
Term
Attending: Semester Quarter Campus to Attend: ______________________________ Date: ___________
Fall Winter Spring Year: ___________ New or Continuing Student
Part I – EMPLOYEE INFORMATION
___Permanent
Circle one: FT PT (If PT – time base ______)
___Temporary FT; Appt. end date ___________
___On Educational Leave or approved leave of
Absence
Part 2 – COURSE INFORMATION
• Courses for purpose of improving level of skill needed to
perform existing duties OR
• Acquiring additional skills to perform newly assigned duties
and responsibilities.
As a Work Related Student you are subject to the
following:
o Academic evaluation process waived for
acceptance by Admissions Office.
o Unable to declare a major, nor can a
degree be conferred
o Required to remain in good academic
standing
o Waived fees are not subject to taxation.
___ Undergraduate Level Coursework ___ Graduate Coursework
_____________________________________ Previous Institution Attended
• Courses being taken for purpose of matriculating towards a
degree or advancing academic degree
• Enhancing the employees career in the CSU system
• Waived fees are subject to taxation*
*Employees enrolled in a CSU masters’ or doctoral program will be subject to
IRS Code 127 limit of $5,250 annually. If the value of these courses exceeds the
limit, the difference will be reported to the State Controller’s Office. Once
reported, this amount will appear as taxable income on a single month’s pay
warrant and the applicable taxes will be deducted. The value of these taxable
fringe benefits will be reported in the November and April pay periods.
Degree Objective:
___ Bachelor’s ___ Master’s ___Credential Certificate ___ Doctorate
How many courses do you intend to take? ______
How many units total? ______
Will you need to take one or more fee waiver courses during regularly scheduled work hours? ______
County of Residence ___________________________________________________________
Part 3 – EMPLOYEE VERIFICATION AND SIGNATURE
My signature below is to certify that the information relevant to this request for Employee Fee Waiver is accurate and I acknowledge that I must submit a new form if I wish to request
a change (e.g., a different class, adjusted work schedule, etc.). Also, as requested by CSU policy, I agree to provide information concerning my study program and grades received by
hereby authorizing the Registrar’s Office to release my transcript of the work completed to Human Resources. Further, I understand that CSU in no way guarantees that completion of
this coursework will result in promotion or other advancements.
Part 4 – Departmental Review and Approval
I grant my employees request to take one or more fee waiver course
during regularly scheduled work hours? ____Yes ____No
Days and times: ___________________________________________
_________________________________________________________
If Yes – Will this require a change in
the employees regular work
schedule? ___Yes ___ No
Individual Development Plan on
file? (Contact HR for Form)
___Yes ___ No
Supervisor/or Appropriate Administrator Signature:
Employee is:
____ Eligible for Fee Waiver ___Not eligible (Reason:_____________________________________)
____ Exempt ____ Non-Exempt
Position # 265 - - CBID: __________
Fee Waiver Coordinator Signature: Date:
edited 2/07/17 – jk
