Waiver Request Form

APO:11/11

Please review your printed document to be sure all typed information is viewable.

Name: Department:

Proposed Title: and Step:

Annual Salary Rate: $ Actual Salary: $

Proposed WAIVER Begin Date: WAIVER End Date:

Percent Time: Fiscal Year Basis Academic Year Basis

Dates of previous waivers: 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 10 lines.

JUSTIFICATION FOR WAIVER ( Refer to CAPM 100.500 ) Attach c.v. for EVERY waiver request:
Text box is limited to 20 lines.

SIGNATURES (Academic Salary Budgetary Authority)

X____________________________________________       X_____________________________________________ _________________
PRINT NAME AND TITLE (e.g. Department Chair/Unit Head/P.I.)   SIGNATURE         Date
   
X__________________________________________________________________________________________ _________________
Dean Date
   
X__________________________________________________________________________________________ _________________
Pamela G. Peterson, Assistant Vice Chancellor,
Academic Personnel
Date

Other Comments (impact on current appointments, etc...):
Text box is limited to 5 lines