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! R n' n' _! n' _! s " " s " n' V B : ADELPHI UNIVERSITY SCHOOL OF SOCIAL WORK
Application for Tuition Remission
Student Name: _____________________________________ AU ID# _____________ Campus: ______
Address: ________________________________________________________________________
Daytime Phone # ___________________________ email: _________________________________
Educational Level: Undergraduate Graduate Post Masters
Name of Agency/Division: ___________________________________________________________
Name of Director/Coordinator: ________________________________________________________
Address: _________________________________________ email: ___________________________
Tuition Remission Request Date: ________________________
Which semester are you requesting Tuition Remission for? Fall 22 Spring 23 Summer 23
Number of Tuition Remission Credits to be allocated to student ..
(Please note: Students may utilize Tuition Remission credits to satisfy up to 50% of enrolled credits to a maximum of 6 credits per semester)
List all the courses you will be enrolled in for the semester in question (form will be returned if this information is not provided):
Course Number Credits Course Number Credits
_____________________ ______ 4. __________________ ______
_____________________ ______ 5. __________________ ______
_____________________ ______ 6. __________________ ______
OR
Continuing Education Certificate Program Course - ____________________________ 30% of Course Fee.
*By signing below, you acknowledge that you have read the Tuition Remission Policy, and you are complying with the policy of the School of Social Work.
Signature of Student Requesting Remission Signature of Agency Director or Educational Coordinator
Note: Forms which are not signed by an officer of your agency will be returned.
**Applications should be submitted by the Classes Begin Date to avoid possible changes in financial packages.
Return original, completed application to: Pat Durecko, 鶹ֱ, School of Social Work-Room 205,
One South Avenue, Garden City, New York 11530
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