Contents
Cal Poly Pomona

Petition Form

Print this page or download and print the PDF file of this form, fill in the information and submit it by mail to the Office of the Vice President for Administrative Affairs, Bldg 98-T6-23. If you have questions, see contact information below.

Petition to Establish or Adjust a Campus-based Student Fee

Unit / Dept. _______________________________________________________________

Submitted by _______________________________________ Date __________________

Description and Impact

A. Briefly summarize the purpose of the proposed fee. (Please feel free to attach any background material desired not to exceed 3 pages excluding the letter of endorsement)

B. Describe the quantitative impact.

  1. Is this a cost recovery or is this for cost recovery plus a margin?
  2. What are the measurable benefits to the students?
  3. What are the measurable benefits to the University?

C. Exact amount of proposed fee $___________

Requested implementation date: _______________________ (quarter) __________ (year)
                                                   (fall; winter; spring; summer)

Describe how you derived this cost. (Resources and costs needed to provide service)

D. Describe the qualitative impact.

  1. Describe the value to the students, the University, the department.
  2. What is the effect on enrollment? Will it increase demand, perception, etc.?
  3. Describe long-term goals to be achieved.

E. Will there be financial aid assistance available for students?

F. How does this fee facilitate access to University services?

Check one: This a new fee ____    This is an existing fee ____

  • How was this program or activity funded previously?
  • Why isn't this program or activity being funded any longer? Please provide documentation of past budget detail.
  • What are the reasons for the increase?
  • When was the last time this fee was increased?

Attach a letter of endorsement. Include signatures of Vice President & Dean/Chair/Dept. Head

A representative from your department is required to attend the next meeting of the Fee Advisory Committee to be available to answer questions as the committee reviews your fee request.

Please contact Ms. Pam Shedd at extension 3019.