<p>Name of Fee: Date Requested: </p><p>Date Fee to be Effective: </p><p>Fee Type: ☐ Executive MBA Program Fee</p><p>☐ Programs and Services Fee (student activity, health service, debt service, campus recreation, campus improvement, counseling) </p><p>☐ Other Dedicated Fee (Athletics, Technology, Facilities, Transportation, Engineering, Graduation/Yearbook, Green Fee, Law Fee) </p><p>☐ Special Course Fee (labs, music, program materials and equipment, field trips, international travel)</p><p>☐ Application Fee</p><p>☐ Online Course Fee (UT Online, ACCLAIM)</p><p>☐ Other (Specify): </p><p>Amount of Proposed Fee or Change in Fee: $ </p><p>Estimated fiscal impact: $ </p><p>Background Information: (If additional space is needed, please attach a separate sheet.)</p><p>Rationale for Fee Change: (If additional space is needed, please attach a separate sheet.)</p><p>Cost Basis for Fee: (If additional space is needed, please attach a separate sheet.)</p><p>Supplemental Information Attached (check): ☐ Peer Comparison Information ☐ Student Polling Results</p><p>Approval:</p><p>Department Date Vice Chancellor Date</p><p>Dean/Director Date Chancellor Date</p>