Student Wage Exception Form

Name ___________________________________________ Social Security # ____________________

Hourly Rate Requested ____________________________ Effective Date _____________________

Department _____________________________________________ Dept. Phone # ________________

Job Duties & Responsibilities of Position for which Exception is Requested

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Qualifications of Student - Specify, in detail, student's qualifications, to include
education, work experience, etc.

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Signature of Department Head or Representative             Date

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Signature of Director of Personnel Services                Date

Instructions - Fill this form completely and sign it, then take it to the Admin Services
office, room 2177D. Attach an additional sheet if more space is needed in either the "Job
Duties & Responsibilities" or "Qualification of Student" sections above.