Request Waiver of Student Fees (for internships only)

Faculty and Staff Use Only

This form is intended for Faculty and Staff use only. Student use is prohibited. Please contact your academic advisor for more information.

- The instructor completes this form, obtains the approval of the department head, and submits it to the University Registrar’s Office.
- A separate form must be used for each course and/or if more students are in the course than can be listed on one form.
Student Information
Last 4 Digits of Student ID:*
Student's Legal Name*
First Last
Student's Home Address*
Street Address Address Line 2 City State ZIP Code
Placement*
Organization City State
Course Information
Instructor Name*
First Last
Instructor Email*
Course*

Course Number and Section (e.g., ENG 101-04)
Department*
Department Information
Department Head Email*

University Registrar's Office