WAIVER REQUEST FORM

Name: Department:

Proposed Title: and Step:

Annual Salary Rate: $ Actual Salary Rate: $

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:
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WAIVER REQUEST (Describe the duties of the position):
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JUSTIFICATION FOR WAIVER (Refer to CAPM 100.500. Attach c.v. for EVERY waiver request:
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SIGNATURES (Academic Salary Budgetary Authority)

_____________________________________________________________________________________________________	______________________________
PRINT NAME AND TITLE (e.g. Department Chair/Unit Head/P.I.) SIGNATURE	Date

_____________________________________________________________________________________________________	______________________________
Dean	Date

_____________________________________________________________________________________________________	______________________________
Pamela G. Peterson, Assistant Vice Chancellor, Academic Personnel Office	Date


Other Comments (impact on current appointments, etc...):
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	APO:11/11