SECTION I - TO BE COMPLETED BY EMPLOYEE. QUESTIONS SHOULD BE DIRECTED TO HUMAN RESOURCES.

UNIT (PLEASE CHECK ONE) *

RELATIONSHIP TO THE KU EMPLOYEE * 🛈

Dependent Child

Dependent Step-Child

Spouse

Student First Name *

Student M

Student Last Name *

New MyKU ID *

SEMESTER (PLEASE CHECK ONE) * 🛈

Semester Year *

EMPLOYING UNIVERSITY: KUTZTOWN UNIVERSITY

Employee First Name *

Employee M

Employee Last Name *

Employee ID 🛈

Email Address * 🛈

EMPLOYEE STATUS (PLEASE CHECK ONE) *

Active

Retiree

Job Title

Years of Service 🛈

INDEPENDENT STUDY / INDIVIDUALIZED INSTRUCTION COURSES ARE NOT COVERED BY TUITION WAIVER FOR AFSCME, MANAGEMENT, OPEIU, SCUPA, SPFPA and POA.

*Employees of AFSCME, OPEIU, SPFPA and POA units must have completed their probationary period prior to beginning of attending semester to be eligible for tuition waivers. NO spousal tuition waiver for OPEIU.

Note: This application should be submitted no later than eight weeks prior to the deadline for payment each semester. The tuition waiver is applicable until the student obtains his/her first undergraduate degree.

Does this student have an undergraduate degree from any college/university? * 🛈

Yes

No

Is DEPENDENT CHILD 25 years of age on the first day of semester? * 🛈

Yes

No

Is this the student first semester applying for tuition waiver at Kutztown University ? * 🛈

Yes

No

Is dependent or spouse on your medical benefits plan? * 🛈

Yes

No

Date of Birth * +

Marriage date * +

Please select your preference to submit the document. * 🛈

Fax to HR private line at 610-683-4641

Attach a file

Deliver in person

Other Other

Attached a proof of age document for DEPENDENT CHILD (Examples: birth certificate, passport or driver license) and a marriage certificate for SPOUSE. *

Note: Student is not eligible for tuition waiver at this time based on your response to the eligibility questions. Please contact Human Resources at 610-683-1353 for assistance.

Note: Your tuition waiver will be held until Human Resources received the proof of age document. Please bring a copy to the Kemp Building as soon as possible.

I certify that the above information is accurate to the best of my knowledge and belief. I further certify that the student named above meets all the normal academic requirements for admission to Kutztown University, and is pursuing his/her first undergraduate degree. I understand that willful falsification of any of this information could subject me to the full cost of the tuition being waived, and such other penalties as applicable laws and regulations may permit.

Employee's Signature (you may sign with your mouse or sign with fingers on a touch screen device) *

clear

DATE * 🛈 +