Music Lesson Facility Fee Form

Employee Name(Required)

First Last

Employee Email(Required)

Which month is this submission for?(Required)

Number of Hours(Required)

The facility fee is $10.00 per hour

Total Cost

Attestation Statement(Required)

I acknowledge and agree that the applicable hourly fee, based on the total number of hours I use St. Olaf College facilities, will be deducted from my paycheck the following month. If my employment with St. Olaf College ends before the full amount has been deducted, I agree to pay the College directly any outstanding balance owed.

Name (Signature)(Required)

Today's Date (For Signature Purposes)(Required)