Waiver Request Form
Please review your printed document to be sure all typed information is viewable.
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)
|PRINT NAME AND TITLE (e.g. Department Chair/Unit Head/P.I.) SIGNATURE||Date|
|Pamela G. Peterson, Assistant Vice Chancellor,
Other Comments (impact on current appointments, etc...):
Text box is limited to 5 lines