Section I:  TO BE FILLED OUT BY ELIGIBLE STATE EMPLOYEE (Only one name per form.)

To:	Registrar:      
			      (Name of State Community College, State College, or University of Massachusetts Campus)

Subject:	Certificate of Eligibility for Tuition Remission for (check one)
		  State Agency Employee	  Spouse of State Agency Employee

The state employee or his/her spouse named below is eligible for tuition remission for      
	(Academic semester and year)

Section II A:  TO BE FILLED OUT BY ELIGIBLE STATE EMPLOYEE

Employee Name:       	Social Security #:        -          -        

Work Phone:  (     )          -                  	Employee ID#:       

Agency:       	Today’s Date:  Month       Day       Year     

Agency Address:      	  Management Level:  M -      

City:       	Zip:       	  Collective Bargaining Unit:      
		            (If none, indicate “no unit”)	
Employee/Spouse Home Address:
     	City:       	           State:    	Zip:      

Section II B:  TO BE FILLED OUT IF USED FOR ELIGIBLE STATE EMPLOYEE’S SPOUSE

Spouse’s Name:       	Social Security #:        -          -        

IMPORTANT!!  Employee Signature Required:

    I certify that the above information in Sections I, IIA and IIB are true:

Section III:  VOLUNTARY INFORMATION (For eligible employee)

Gender:   Male  Female             Disability:   Yes    No                  Veteran:   Yes    No
Race:       Black    Asian/Pacific Islander    Hispanic    Native American   White   Other      

Section IV:  TO BE FILLED OUT BY THE HUMAN RESOURCES DIRECTOR/DESIGNEE
Basis for Eligibility:
1. Employed full time:   Yes    No	2. Agency Code#:      	Position #:      
3. Entry date to State Service:  Month       Day       Year     
4. Date completed 6 months full-time or equivalent service:  Month       Day       Year     
5. Proof of Marriage: (Describe Proof)      
6. H.R. Director/Designee Signature:	Phone: (     )          -       

Section V:  TO BE FILLED OUT BY AGENCY AUTHORIZED SIGNATORY AUTHORITY

Certified Eligible By:

Agency Head/Designee Title:	Phone: (         )            -   
	
Agency Head/Designee Signature:	Date: Month        Day         Year 

CERTIFICATE VALID FOR 120 DAYS FROM DATE OF ISSUE BY SIGNATORY AUTHORITY
DO NOT SEND TO THE HUMAN RESOURCES DIVISION