Application for Utah State University Moab Academic Tuition Waiver for Fall 2012 Please complete the

application, provide documentation materials, and return to Sam Sturman at the USU Moab Center on or before Monday August 21, 2012 at 5:00 P.M.

Academic Tuition Waiver for Fall 2012 $400 each semester

Criteria: 1. Awarded students agree to have a registration hold placed on their account at time of award. Any changes to a students registration after the award date must be coordinated with the USU Moab advisor. The award will be completely reversed if attempted credit hours fall below six credits during the term for undergraduate or graduate students during the term. 2. Undergraduate or a Masters student must be enrolled in 6 or more credits. 3. The highest cumulative GPA from the school last attended (college or high school or GED) will be considered for awarding waivers. (Submit a copy of your transcript with the application that shows the GPA or score.) In the event of a tie; the applications that were submitted first and initialed by a USU representative will be considered in submission order. 4. This award is not redeemable for cash for refund. 5. Waiver cannot be used with any other USU scholarship or tuition waiver. 6. Waiver is renewable for Spring 2013 if your Fall semester GPA is 3.0 or higher. 7. You can be a new or renewing student attending USU Moab to apply. 8. You must be an admitted and attending Utah State University Moab for the Fall semester and taking 6 or more credits (Please submit verifying information of acceptance to USU and the courses you are taking) Name _______________________________________________________________________________________ Last First USU A# ____________________________ Email Address _______________________________________ ________________________________________________________________________________________________ Street Address or Box City State Zip Telephone Number (_____) _____________________________ I certify the information provided on this application is correct to the best of my knowledge and I authorize the release of this information and/or my transcripts to anyone or institution involved in the awarding of the above waiver.

Signature July 17, 2012 (Official Use Only)

Date Date Received by USU ____________________ Initials USU Representative ________________