Lock Haven University of PennsylvaniaTuition Waiver

SECTION I (To be completed in its entirety by student and/or employee after verifying eligibility. Questions relating toeligibility should be directed to the Benefits staff in the Human Resources Department.

Please Note:

? Tuition Waiver forms will not be approved more than eight (8) weeks before the start of the semester for which the waiver isrequested.

? A separate form must be submitted for each semester. Forms requesting multiple semester waivers will not be processed.? Applications must be submitted prior to the beginning of each term.? Applications filed after the completion date of the course(s) will not be considered.

Student's Name: Social Security # (new student):

Student ID # (returning student): Date of Birth:

Semester: (Please check one)

Fall 20 Spring 20

Summer I 20

Summer II 20

Extended Summer 20

Total Credit Hours Enrolled (Please reference applicable tuition waiver policy for employee waiver limits)Relationship to the LHU employee (Check one):

Self* Spouse Child Domestic PartnerAge at beginning of semester (for children of employees only):Already have undergraduate degree from LHU or other university/college: Yes NoCourse Level to be taken: Undergraduate Graduate (Waiver for Coaches & Faculty only not dependents)If self:*Have accumulated 128 or more credits from LHU: Yes No*Tuition waiver limited to 6 sh. per academic term and all summer

semesterexcept for faculty andcoaches

Employee's N ame:

Telephone Number:

Employee Cost Center:

Status: Active Retiree

Che ck One (To be completed by employee):(Note: AFSCME, SCUPA & SPFPA employees must have or will complete their six month probationary period by the last day of drop/add period.)

AFSCME (see note above)APSCUF (Faculty) SPFPA (see note above)Management SCUPANon-faculty Athletic Coach

I certify that all of the information listed aboveis accurate and I understand that it may be subject to audit. Failure to provide complete andaccurate information may result in denial of the benefit and/or disciplinary action.

Student's Signature: Date:

Employee's Signature: Date:

SECTION II (To be completed by Human Resources Representative)

Approving Signature: Date:

Waiver Percentage:

Winter Intersession 20