Request for Registration Fee Discount for Spouse/Dependent of Employee Form	PMGS 17-B 06-29-2017
Spouse/Dependent Information
Name	Student School ID #
Last Name, First Name
Relationship to Employee	Spouse	Unmarried Dependent
Student’s Designated Campus on File with Human Resources
Enrollment at	CCCUA eVersity PCCUA UACCB UACCH UACCM
UAFS UALR UAM UAF UAMS UAPB UAPTC
Course Location	Degree Sought
Student Status	FR	SO	JR	SR
Academic Year	Fall	Spring	Summer I	Summer II
Short-Term Interim Course	Summer III	Summer IV
Number of credit hours enrolling this semester	Total accumulated to date
Course Name	Course Number	Credit Hours	Days/Times of Class Meeting(s)
Employee Verification
Employee Name	Employee ID
Employee Title	Employee Date of Hire
Employee Work Email
Please Read Carefully
I have reviewed policy PMGS 17-1 and certify that the above student is my spouse or unmarried dependent child as defined by the Internal Revenue Service. I agree to furnish documentation, if requested, in support of the validity of the above statements, including copies of federal and state income tax returns as may be necessary to confirm my claim of dependent status. I also certify that I am currently serving the University in a full-time capacity.
Employee Signature	Date
Human Resources Representative Signature	Date

The Student’s Designated Campus selected for tuition discount purposes is a permanent choice.

Benefit not available for Medical, Law, or Graduate School.

There is a 132 credit hour maximum at the tuition discount rate.