REQUEST FOR FACULTY/STAFF TUITION WAIVER
Please complete all requested information and return to the Office of Human Resources for all approvals.
EMPLOYEE
Last Name:_____________________________________First Name:___________________________________MI:______
XUID:_______-_______-_________XU Email:________________@xula.edu
Department:_________________________
Circle One: Faculty
Staff
Position:_____________________________
Date of Hire: ___/____/________
ENROLLMENT
Semester of Waiver Request (Must complete a new form each semester)
Circle One: Fall
Spring Year:___________________
Circle One: Graduate
Undergraduate
Major Course of Study____________________________________________
Course Title____________________________________________________Course Number______________
Credit Hrs._________ Days & Times________________
PLEASE EXPLAIN HOW THIS COURSE RELATES OR WILL RELATE TO YOUR JOB ASSIGNMENTS WITH THE UNIVERSITY:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I understand that only one course each semester is available to me tuition free as an undergraduate in College of Arts and
Sciences. I understand that one-third tuition waiver is also available to me for graduate level courses. I understand that the
subject must be related to my work or anticipated future assignments and that the class can be taken during regular office
hours. I understand that I am to attend class during designated class times; however I may be exempted by my immediate
supervisor due to work or other unavoidable circumstances. I am also aware that successful completion of this course in no way
guarantees my salary or job advancement with the University.
SIGNATURES
I ATTEST THAT THE ABOVE INFORMATION IS TRUE
____________________________________________________________________________ _______/_____/_______
Employee’s Signature
Date
____________________________________________________________________________ ______/_____ /________
Immediate Supervisor’s Signature
Date
____________________________________________________________________________ _______/_____/_______
Dean/Administrative Director/VP of Department’s Signature
Date
RETURN FORM TO HUMAN RESOURCES FOR BELOW APPROVAL
____________________________________________________________________________ _______/_____/_______
Director of Human Resources’ (Employment & Benefits) Signature
Date
____________________________________________________________________________ $____________________
Fiscal Services’ Representative Signature
Remission Amount
Rev 1.14