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
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Student Card Acceptance Form - Mississippi PDF

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