Revised: 07/25/2019
Faculty/Staff Payroll Deduction Application for Food Court
Name_________________________________________________ ID ______________________
Last First Middle Banner ID Number
Address________________________________________________________________________
Street City State Zip Phone
The MSU – Northern payroll deduction program give you access to delicious, nutritious, and
convenient meal options right here on campus. The Northern Lights Food Court provides many dining
options at an affordable price. Through the payroll deduction program, funds will automatically be
loaded onto your North Card to be used in the Northern Lights Food Court through a declining balance
program. With the a la cart pricing, you only pay for the items you choose. You can pick up just a drink
or an entire meal and pay with your North Card. You may use these funds at any time throughout the
semester.
The one time block funds have an added advantage: for every $50 allocated, receive an additional $5!
Due to this special pricing, one time block funds are not refundable.
Please deduct the amounts from my monthly paycheck for:
Fall (August-December) 20_______ Spring (January-May) 20 _________
Please select the payroll deduction method below:
$_____per
month $_____ one time deduction
B
y signing this form, I authorize the Montana State University – Northern Business Office to deduct the amount
above from my monthly paycheck to be placed on my North Card for use in the Northern Lights Food Court. I
have read, understand, and agree to all of the terms and conditions of this application.
_________________________________________________________________________________
____
(Signature) (Date)
A
ll fees are subject to change and reflect US Dollars.
A
ll forms are to be mailed to: *** OFFICE USE ONLY ***
Business Office DATE___________________________________
PO Box 7751
Havre, MT 59501 SIGNED CONTRACT ______________________
Questions or Concerns? Please call the Food Service Office at (406)265-3796 or the Business Office at (406)
265-3733 or e-mail Becky Toth, Food Service Manager at becky.toth@msun.edu
