Third Party Authorization for Payment
Accounting & Fees * 7411 Eighty-Fifth Avenue North * Brooklyn Park, MN 55445
Phone: (763) 424-0718 option 2 * Email:
Updated 07/17/2020 For disability accommodations call 763-493-0555. Minnesota Relay users may call 1-800-627-3529.
All required fields must be completed or the authorization will not be accepted.
Please complete online prior to printing and emailing.
Student Information
Tech or Star ID
Agency/Funding Information
Purchase Order or Authorization #
Federal ID #
Contact Name
Billing Email
Billing Address
Phone #
Term Covered by funding (one term only)
Tuition & Fees
School Supplies
Enter either the maximum dollar amount and/or
check box for 100% covered by funding
Sales Tax Exemption # (Supplies if authorized)
Total authorized $
Check One (Required)
Apply this funding before any grants
Apply grants first before this funding
By authorizing funding for the above referenced student; I agree to pay all invoices by the due date noted on the invoice. I
understand I will not be invoiced until after the drop / add period, only for actual costs up to the amount authorized and all
invoices are sent via email to the billing email address listed above. If invoices are not paid by the due date, the balance
will be returned to the student’s account and the collection process will begin.
Authorized Signature
DATA PRIVACY NOTICE: North Hennepin Community College is asking you to provide information that includes private and/or
confidential information under state and federal law. The college is asking for this information in order to process your third-party funding.
You are not legally required to provide the information the college is requesting; however, the college will not be able to process your
funding without it. With some exceptions, unless you consent to further release of private information, access to this information will be
limited to business office officials. Under certain circumstances, federal and state laws authorize release of private information without
your consent:
To federal, state and local officials for purposes of program compliance, audit or evaluation;
If the information is sought with a subpoena, court order, or otherwise permitted by other state or federal law, and
To an organization engaged in educational research or accrediting agency.
North Hennepin Community College abides by the provision of Title IX and other federal and state laws forbidding discrimination on the
bases of sex, race, color, national origin or disability and all other state and federal laws regarding equal opportunity.
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