2012-2013 Annual Fund Employee Payroll Deduction Form To set up your contribution to the NHCC Foundation as an automatic payroll deduction, submit this completed form to Jennifer Summer Lambrecht (JSummer-Lambrecht@nhcc.edu or ES-32). Name: Home Address: City, State, Zip: Home Phone: E-mail:
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I would like to make a payroll contribution of $ per check. Please continue my payroll deduction at my current rate. I do not want my name to be published in donor listings, thank you.
If you deduct this amount per check
This will be your annual contributio n
$5
$130
Which could cover the following items for students Textbook or supplies
$10
$260
1 credit + 1 book
$15
$390
2 credits + supplies
$20
$520
3 credit class
$25
$650
4 credit class
Please discontinue my payroll deduction with the next pay-period. (Submit this form to Karen Melin in Human Resources).
Signature:
Date:
North Hennepin Community College Foundation | 7411 85th Avenue North | Brooklyn Park, MN 55445 | 763-424-0815| foundation@nhcc.edu Member of the Minnesota State Colleges and Universities System and an Equal Opportunity Educator and Employer. For disability accommodations call 763-493-0555. Minnesota Relay users may call 1-800-627-3529.