Fillable Printable Student Card Acceptance Form - Mississippi

Student Card Acceptance Form - Mississippi

1 | P a g e

The University of Southern Mississippi

Student Card Acceptance Form

I hereby agree to comply with the terms and conditions of this Procurement and Contract Services

Student Card Acceptance form as outlined in the Student I.D. Card Policy and Procedures at

I hereby agree to use my best effort to minimize exposure from lost, stolen, or otherwise compromised

cards. I accept the benefit(s) given to me by signing this Acceptance Form. I understand that the

University WILL report this benefit to the IRS if a “student worker” or through Financial Aid if a

“scholarship”:

Requirements and Responsibilities:



Must be a current student of USM in good academic standing



Department must indicate whether benefit is result of student employment or scholarship



Assure that the budget authority has signed and all documentation is completed

I hereby understand that the University may terminate my right to use these funds at any time and for any

reason. I hereby agree to return these funds to Eagle Dining or my department supervisor immediately

upon request from the University, when transferring out of my department, upon termination of

employment, or academic suspension.

Department Information *Please check one*

(1) Student Worker ______

Department Name ________________________________________ (2) Scholarship

______

Box Number _____________________

(3) Working Condition

Fringe Benefit

______

Phone Number _____________________

Email Address ____________________________________

Budget String ________________________________________________________________________

Purpose ________________________________________________________________________

Date Requested _____________________________

Date Needed _____________________________

Name ID Number Dining Dollars per Card Meals per Card Date Range

*For Internal

Use Only*

Event# _______

___________________________________________ _____________________________

Department Applicant Signature Date Printed Name

___________________________________________ _____________________________

Department Head/Administrator Signature Date Printed Name

2 | P a g e

UPDATED: 2/8/2010 9:52 AM

(1) Student Worker ______

Department Name ________________________________________ (2) Scholarship

______

Budget String ___________________________________________________ (3) Working Condition

Purpose ___________________________________________________ Fringe Benefit

______

Department Head Signature ________________________________________

*For Internal

Use Only*

Date Requested _____________________________

Date Needed _____________________________

Event#

_______

Name ID Number Dining Dollars per Card Meals per Card Date Range