SPECIAL FEES REQUEST FORM
Office of Academic and Student Affairs
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Div/Dept:________________________________   Date:______________________

Course ID:_______________     Course Title:_______________________________
 

Current Fee/Codes:

Amount: $________ Fee Code:____  Trans Code: ___ Type (flat or hourly): ______
Amount: $________ Fee Code:____  Trans Code: ___ Type (flat or hourly): ______
Amount: $________ Fee Code:____  Trans Code: ___ Type (flat or hourly): ______

               $________   TOTAL FEE   Established Date:__________________

Proposed Fee/Codes:

Amount: $________ Fee Code: ____  Trans Code:___ Type (flat or hourly): ______
Amount: $________ Fee Code: ____  Trans Code:___ Type (flat or hourly): ______
Amount: $________ Fee Code: ____  Trans Code:___ Type (flat or hourly): ______

               $________  TOTAL FEE              Effective Term:___________________

 # of Students Annually:______________

Rationale:____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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SIGNATURES REQUIRED:

__________________________       ____________________________         ________________________
Division/Department Chair  - Date    Vice/Associate Vice President  - Date    President - Date

(Return to OASA after President’s signature)
Original to: Office of Academic and Student Affairs    Copies to: Enrollment Services/Operations
                                                                                     Curriculum & Scheduling/Scheduling Specialist
                                                                                         Originating Department