WAIVER REQUEST FORM

This form is designed to print on one page. Please review your printed document to be sure all typed information is viewable.

Name: Department:

Account Name/Number (fund source):
Proposed Title: and Step:
Proposed Begin Date: End Date: Pcent Time:
Alien Registration Number: Visa type: Visa expiration date:
Date granted immigrant status:
Dates of previous waviers: Dates of previous search:

Prior and/or concurrent UC employment (state location, dates, titles:
Text box is limited to 4 lines.

WAIVER REQUEST (Describe the duties of the position):
Text box is limited to 15 lines.

JUSTIFICATION FOR WAIVER (Refer to CAPM 100.500. Attach c.v. for EVERY waiver request:
Text box is limited to 30 lines.

 

SIGNATURES (Academic Salary Budgetary Authority)

________________________________________________________________________________ ______________________________
NAME (e.g. Department Chair/Unit Head/P.I.)           TITLE Date
   
________________________________________________________________________________ ______________________________
Dean Date
   
________________________________________________________________________________ ______________________________
Pamela G. Peterson, Assistant Vice Chancellor,
Academic Personnel Office 		Date
 
APO:4/09