Application for Tuition Remission

(Best viewed with Internet Explorer 5+ or Netscape 6+)

Attention: Completed application must be submitted at the time of registration or within 21 days of start of classes or the student will be ineligible for tuition remission for that term.

Send SIGNED form to:
Human Resources, Rm. 302, Main Bldg.

(If your browser prints "Office Use" signature lines on a second page, send both pages.)

Check one:
IIT
IITRI

Fall 20
Spring 20
Summer 20

MBA qtr: 20
Fall
Winter
Spring
Summer


Employee/Faculty Member	Social Security #	Date


Position/Department		Extension

Full-time faculty or staff (at least 38.75 hours per week)

Eligible part-time staff (31.00 but less than 38.75 hours per week)

Eligible part-time staff (23.25 - 30.75 hours per week)


Student Receiving Tuition Benefit	Social Security #

Relationship to Employee/Faculty Member:

Self

Spouse/Domestic Partner

Child

	Undergraduate	Graduate
Major
Total credit hours this term:

If auditing a course, please list course(s):

Is student eligible for financial aid?	Yes	No	Financial aid for which the student qualifies may reduce tuition benefits under this policy.
Is student receiving financial aid?	Yes	No

I hereby certify that the above named student, if other than myself, is my legal spouse and/or dependent child as defined by the IRS or an eligible domestic partner. I further certify that I have receive, read, and agree to comply with the provisions of the IIT Tuition Remission Policy.

Employee/Faculty Member Signature		Date

Dept. Chair/Director/Dean Signature		Date

For Office Use Only

IIT:	Employee	44003
	Spouse	44005
	Dep. Child	44004
	Faculty	44000
	Fac. Spouse	44002
	Fac. Child	44001

IITRI:	Employee	44006
	Spouse	44007
	Dep. Child	44008

Undergraduate	_________%

Graduate	_________%

Charge	$_____________


IIT/Human Resources-Approval		IITRI/Corporate Human Resources-Approval