Application for Merchant Account
Send the following request to the Office of the Bursar, Attn: Jennifer Hellwege, 121 Admin Bldg, 0412. For questions contact Jennifer at jhellwege2@unl.edu, 472-9004 or 121 Admin.
DATE: TO: FROM:
_________________________________________ Assistant Vice Chancellor of Business and Finance – Financial Services _________________________________________ (Name)
_________________________________________ (Title: Dean, Director or equivalent) SIGNATURE: _________________________________________
Please approve the issuance of a merchant number to the department of
______________________________________________________ to process credit/debit card payments. My department has read and agrees to follow the UNL Payment Card Policies and Procedures. My department also agrees that we will be responsible for paying any implementation/set up costs as well as the ongoing fees, that we will assume responsibility for any and all risk, and that we will be financially liable for the consequences of the loss of credit card data.
This merchant number is being requested to: (choose one) ______ Provide income from a new product or service. ______ Provide another means of payment for an already existing product of service. (Explain the new or existing product(s) and/or service(s) in an attachment.)
Estimated Annual Sales Volume: _____________________________
This is the amount you expect to collect per year from the payment card option(s).
Estimated Average Ticket Amount: ____________________________
This is an estimate of your average transaction amount. List only one amount, not a range. i.e. $600; not $200 to $1000.
Cards Accepted:
MC _____________ Visa _______________
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Cost Center where income will be deposited: __________________________________ G/L Account Number: __________________________________
Cost Center where fees and expenses will be charged: __________________________________ G/L Account Number: __________________________________
Merchant Name: ______________________________________________________________
The merchant name is limited to 22 characters/spaces and is the name that will appear on your customer’s statements. It should reflect your department in such a way that the customer will recognize the charge. (i.e. UNL Lied Center)
_______ (Please check) Attached to this application is a description of the transaction processing methods and protocol we will employ to conduct our payment card activity. Please include: 1) What type of business you will do {i.e. internet, card-not-present (MOTO –Mail Order/Telephone Order), card-present} 2) what type of equipment you will be using (if known) and 3) the types of products/services payment cards will be used as payment for.
Address to which documents should be mailed – an individual’s name is required on the “Attention” line: ______________________________________________ Attention ______________________________________________ Building Name and Rm # ______________________________________________ City, State and Zip
Contact Information Departmental Contact ________________________________________________________________ Server Administrator Contact __________________________________________________________ Application Support Contact ___________________________________________________________ Accounting Contact ________________________________________ Phone ___________________ Chargeback Contact ________________________________________ Phone ___________________ Chargeback Fax Number __________________________________
Signature of Preparer _________________________________________________________________ Campus Address, if different from above _________________________________________________ Phone # ______________________________ Fax # ______________________________________
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