Employee Request for Registration Fee Discount Form	UADA 440.1-A 02-09-2024
Name	Employee ID
Last Name, First Name	Employee email
Title	County/Dept
Full-Time Active Employee Yes No	Date of Hire
Designated Employee’s Campus on File
Enrollment at	CCCUA UA Grantham PCCUA UACCB UACCH UACCM
UAFS UALR UAM UAF UAMS UAPB UAPTC UARM
Course Location	Degree Sought Bachelors Masters Doctorate
Student ID	Degree Program
Student Status	FR	SO	JR	SR	GR	Non-Degree Seeking
Academic Year	Fall	Spring	Summer I	Summer II
Short-Term Interim Course	Summer III	Summer IV
Course Name	Course Number	Credit Hours	Days/Times of Class Meeting(s)
I pledge that I shall not permit participation in this course to interfere with the performance of my regular duties.
Employee Signature	Date
I certify that the employee is full-time (100% appointed).
Supervisor Signature	Date
Dist. Director/Dept. Head	Date
Next Level Approver (if applicable*)	Date
* Signature is required if Supervisor and Dist. Director/Dept. are the same. Certification of Employment by Home Campus or Unit of University of Arkansas: I certify that the employee meets the eligibility requirements for tuition waiver per the University of Arkansas Division Policy PMGS 17-1. Human Resources Representative __________________________________ Date _____________________________ HR Comments/Notes: _____________________________________________________________________________________

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

Total enrollment at reduced rates shall not exceed eleven (11) credit hours per Fall/Spring term, three (3) credit hours per summer term and shall not exceed a total of 132 undergraduate semester credit hours.