Employee / Dependent Tuition Waiver Request

Directions: Please complete this form for each term in which you are requesting a waiver for you or your qualified dependent. Use a separate form for each person. Denied request will be returned to employees. 

1

Tuition Waiver Request is for: 

 *

Tuition Waiver Request is for:

Employee

Qualified Dependent

2

Classified Employees Only: By Checking the box below I certify that I have received acknowledgement from my supervisor for classes scheduled during my work hours. 

Check Box:

3

Employee Information:

 *

Employee Information:

First Name:	Last Name:
BMCC ID:	Email:

4

Employee Classification

Employee Classification(Select an Answer) Classified Exempt Faculty

5

Dependent Information:

Dependent Information:

First Name:	Last Name:
BMCC ID:	Relationship to Employee:

6

School Term:  Select the term and provide the year for the waiver request. 

 *

School Term: Select the term and provide the year for the waiver request.

Summer	Fall	Winter	Spring
Year:

7

 Course Information:

	Course Number#	Course Name	Credits
-	Course Information:	Course Information:	Course Information:
-	Course Information:	Course Information:	Course Information:
-	Course Information:	Course Information:	Course Information:
-	Course Information:	Course Information:	Course Information:
-	Course Information:	Course Information:	Course Information:
-	Course Information:	Course Information:	Course Information:
-	Course Information:	Course Information:	Course Information:

8

By checking the box below, I acknowledge it is my responsibility to pay any balance due.

 *

Check Box:

Please allow two weeks for processing

---

Waiver eligibility per contracts, memos, and employee hand book. 

1. Distance Education fees are not covered by this waiver. 

2. Waiver includes tuition & fees (other than Distance Education) 

• Exception - Exempt techs with less than 5 years of service are eligible for tuition only. 

---

9

Human Resources Use Only:

Approval:

10

Eligibility

Eligibility

Processed By:

Date

11

Financial Aid Use Only:

Financial Aid Use Only:

Processed By:

Date:

12

Business Office Only:

Business Office Only:

Processed By:

Date:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1