merchant application template

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					                                                                                Oakland University                                                                          Merchant #
                                                                      Credit Card Merchant ID Request                                                                         Routing#
                                                                           (Enter data below labels, please)                                                                      DDA#

                         Department (Merchant) Name:                                                                                         Department Address:

                     Contact Person:                                          Phone:                                                    E-mail:                                                              Fax:

                                           Purpose: Please describe the goods and/or services to be paid for by credit/debit card.

     Account Name To Be Displayed On Customer’s Receipt:                                                              COLLECTION METHODS: CHECK ALL THAT APPLY :
                                                                                                      Card Terminal     Cash Register       PC Based       Telephone       Internet      Fax          Mail           Other

                  OU Address to Print on Customer Receipt:                                           Card Terminal - Stand alone device to process card transaction.
                                                                                                     Cash Register - Unit that tracks cash and processes card transactions.
                    120 North Foundation Hall (Required)                                             PC Based- Software enabling computer to track cash and process card transactions.
     Indicate physical locations if point of sale machines are being used.                                                                             If Internet:
                                                                                                                        URL for website :                                                IP Address:
                        CREDIT CARD PROCESSING
    (Check which method(s) you would like to use to accept credit cards. Default = Terminal)             Gateway:                                Email account for credit card confirmations:
  Credit Card Terminal/Printer            PC Software                      Other
         (Call Student Business Services at 370-2288 for info on PC or Other methods.)
                    CREDIT CARD TERMINAL OPTIONS                                                                         Software (if applicable, attach a flow chart of your credit card process):
# Terminals @ $351 each:           # Printers @ $280 each:            Outside Line Access:
                         (minimum 1)                                   (7) on main campus                      How is Sensitive Cardholder Data Protected? (Attach add'l explanation if needed)
              1                                  1                                 7
       INDICATE ACCOUNTING FOR CHARGEBACKS AND FEES:                                                                   Is Sensitive Cardholder Data Processed on an OU machine?
 Chargebacks (if not set fund/acct, explain) Processing Fees & Equipment Cost
  Fund (5)         Acct (4)                          Fund (5)           Acct (4)                                         Is Sensitive Cardholder Data Stored on an OU machine?

                                                                                                                Is Sensitive Cardholder Data Transmitted on an OU machine or network?
    Please indicate revenue amounts based on current sales if applicable.
  Est. Annual Credit/Debit Volume:                      Anticipated Average Ticket:                          Vice President, Dean or Director Signature:                                                     Date:

                                                                                                   Model/Serial #:                                                                                Truncated?
   SBS Use Only:                          Terminal 1:                                  Printer1:                         Terminal 2:                             Printer 2:                           (Initial/Date)

   Department has received/taken                               Name and Date                                            Name and Date                                                 Name and Date
    A Copy of Policy and Procedures:
            Training Event Attended:

   9a9bda83-d4a6-4a2a-9bf3-c43236b00bbd.xls                            Questions? Call Student Business Services at 248-370-2893                                                                              7/29/2012

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