Office of Human Resources CSU Employee Fee Waiver & Reduction Program Application

OFFICE OF HUMAN RESOURCES TEL NO: (818) 677-2173 FAX NO: (818) 677-5956 MAIL CODE: 8229

THIS APPLICATION MUST BE COMPLETED EACH SEMESTER TO ESTABLISH YOUR ELIGIBILITY FOR THE CSU EMPLOYEE FEE WAIVER AND REDUCTION PROGRAM. THIS FORM MUST BE RETURNED TO THE OFFICE OF HUMAN RESOURCES - MAIL CODE 8229 - UNIVERSITY HALL, RM 185.             SEMESTER:

Last Name:

First Name:

M.I.:

CSUN ID:

CSUN Phone:

Mail Code:

Home Address :

City:

State:

Zip:

Classification / Job Title:

Department:

CSU Campus of Enrollment:

Email Address:

Do you have a BA or BS?

Yes No

PLEASE CHECK ALL THAT APPLY
New Fee Waiver Participant	Continuing Student - No changes	Continuing Student - With changes

Please check one:	Matriculated - I am taking classes toward a degree or credential
	Non-matriculated - I am taking work-related courses
Please check one:	I am submitting a CSUN application with this form (Application fee is waived)
	I have submitted a CSUN application through CSUMENTOR (Application fee is waived)
	I have submitted a CSUN application in a previous term

EMPLOYEE TO COMPLETE AND SIGN THIS SECTION
Bargaining Unit:	Management: Yes No	Faculty: Yes No

Full Time: Yes No	Probationary	Permanent	Temporary
By signing, employee is indicating that the above information is true and correct to the best of their knowledge.
Employee Signature/Date:	_____________________________________________________

FEES & COURSE LIMITS AT CAL STATE NORTHRIDGE
Bargaining Units	Course Limits	Course Level	* Fees 0-6 Units	* Fees over 6 Units
1, 2, 3, 5, 6, 7, 8, 9, and C99, E99, M80	2 courses or 6 Units, whichever is greater	Undergraduate Graduate / Post Bac. Teaching Credential	$ 3	$ 528 $ 651 $ 612
4, M98	2 courses or 6 Units, whichever is greater	Undergraduate Graduate / Post Bac. Teaching Credential	$ 53	$ 528 $ 651 $ 612
THE $ 3.00 OR $ 53.00 FEE IS NONREFUNDABLE AND CANNOT BE CREDITED TO THE NEXT SEMESTER. * IF YOU ARE TAKING OVER 6 UNITS, PLEASE ADD THE 0-6 UNITS FEE AMOUNT FOR 6 UNITS. DO NOT ATTACH PAYMENT TO THIS FORM

HUMAN RESOURCES USE ONLY
_______________________________________________________________________	Eligible: Yes No
PROFESSIONAL DEVELOPMENT OFFICE / DATE: Office of Human Resources - 8229	OHRS 40-10 (Rev. 09/2004)