Fee Request Form

Name of Fee: Date Requested:

Date Fee to be Effective:

Fee Type: ☐ Executive MBA Program Fee

☐ Programs and Services Fee (student activity, health service, debt service, campus recreation, campus improvement, counseling)

☐ Other Dedicated Fee (Athletics, Technology, Facilities, Transportation, Engineering, Graduation/Yearbook, Green Fee, Law Fee)

☐ Special Course Fee (labs, music, program materials and equipment, field trips, international travel)

☐ Application Fee

☐ Online Course Fee (UT Online, ACCLAIM)

☐ Other (Specify):

Amount of Proposed Fee or Change in Fee: $

Estimated fiscal impact: $

Background Information: (If additional space is needed, please attach a separate sheet.)

Rationale for Fee Change: (If additional space is needed, please attach a separate sheet.)

Cost Basis for Fee: (If additional space is needed, please attach a separate sheet.)

Supplemental Information Attached (check): ☐ Peer Comparison Information ☐ Student Polling Results

Approval:

Department Date Vice Chancellor Date

Dean/Director Date Chancellor Date