UW-Madison Tuition Waiver Request Form …

                 UW-Madison Tuition Waiver Request Form
                       Independent Learning - UW-Extension Course

Student Name:

Campus ID:

Academic Career (circle one):      Undergraduate        Graduate       Professional       Special

College or School:

I am requesting to carry (course name/number) __________________________________________________

for (number) _______ credits through Independent Learning for (term) ______________________________.

________________________________________________________                      ___________________________
                     Student's signature                                                  Date


                For Official Use - To Be Completed by Dean's Office Staff

  This course may be taken concurrently with (number) _____ credits in residence on UW-Madison campus.

  The course                will             will not                count for degree credit.
  The course                will             will not                count for senior residency credit.
  The course                will             will not                count for major residency credit.

  Additional school/college contingencies (e.g., course completion date):




  Based upon current enrollment, separate fees               need not be paid.
                                                             are the responsibility of the student.
  School/College Dean's Approval:

  Name:         _____________________________________________________________________

  Date:         _____________________________________________________________________




   The student is responsible for making three copies of this form. Original to UW Learning
 Innovations, copies to school/college student file and to student. Form date: September, 2006.

Important notes: The UW-Extension transcript date may determine the effective UW-Madison graduation
date and semester. Students are responsible for monitoring UW-Madison graduation deadlines. Students must
allow a sufficient period of time for evaluating course work and posting grades to the official UW-Extension
transcript. Confer with your dean's office regarding these issues. To request that an official transcript be sent
to UW-Madison Undergraduate Admissions, send the form found in each course guide, along with fee, to
UW-Extension Student Records, Pyle Center, 702 Langdon Street, Room 139, 608-262-1953.