GRADUATE COLLEGE
EXTERNALLY FUNDED TUITION WAIVER FORM
This form must be completed and signed by the student and hiring department/unit.
Please type or print clearly in blue or black ink.
STUDENT INFORMATION
NSHE ID:
Hiring Department/Unit:
First Name:
Last Name:
Rebelmail:
Phone:
Subject Prefix
Course Number
# of Credits
(ex. MBA)
(ex. 702)
(ex. 3)
TOTAL CREDITS:
STUDENT SIGNATURE – By signing below, I certify all information included on this form to be accurate.
STUDENT SIGNATURE
DATE
THIS SECTION IS TO BE COMPLETED BY HIRING DEPARTMENT/UNIT ONLY
Tuition and fees to be paid out of the following account:
(Account number)
DEPARTMENT APPROVAL
By signing below, I certify that the account number listed above has the funds necessary to pay the tuition (the number of credits
and rate to be paid) and fee amounts as I specified in AY-GA.
PRINT NAME
SIGNATURE
DATE
* THIS SECTION IS FOR GRADUATE COLLEGE USE ONLY *
Per GA Department Request Form in AY-GA:
credits full tuition ($264.00 per credit)
=$
credits partial tuition ($197.59 per credit)
=$
credits supplementing state waiver ($66.41 per credit)
=$
All special fees up to
Partial special fees of $
$
credits
Special fees per length of contract are $
toward health insurance premium
Health insurance to be paid from same account as stipend
Health insurance to be paid from the following account:
GC Staff Initials: