DIXIE STATE COLLEGE TUITION WAIVER
EMPLOYEE NAME: SSN:

FACULTY: STAFF: RETIRED: ADJUNCT: PART-TIME:

(Adjunct and Regular Part Time requires Supervisor's Signature)
DEPARTMENT: SEMESTER:
                                                                                                     CREDIT HOURS: 
SPOUSE OR DEPENDENT STUDENT(S):

SPOUSE'S NAME

SSN

CREDITS

DEPENDENT'S NAME

SSN

BIRTHDATE

MARRIED?

CREDITS
FOR STAFF EMPLOYEES:
Staff may take up to a 4 credit class during the regular work day if working towards a certificate or degree or if required by the supervisor as job training. (Exceptions to policy must be justified and approved by supervisor and vice-president.) Complete the following information for required classes and obtain supervisor's (and vice-president's) signature(s):

CLASS

TIME/DAYS

JUSTIFICATION

SIGNATURES:


SUPERVISOR:___________________________     VICE-PRESIDENT:_____________________

EMPLOYEE:________________________________          DATE:_______________

HUMAN RESOURCES:_________________________      DATE:_______________