Credit Card Machine

							                                  Georgia Southern University
                                  Credit Card Machine
                                              Order Form
                                                (please print)

Date of request ________________
New Machine                  Replacement Machine
Name of Account: ___________________________________________ (Business Name)
Contact Person: _______________________________ Phone: ____________________
Location of Machine: _______________________________________ (Department name)
                          _________________________________(Building & room number)
                          _______________________________(Street Name, City, State, Zip)
Software application to be used: ______________________________________________
Services Provided: ________________________________________________________
________________________________________________________________________
Estimated Average Ticket Amount: $___________________
Estimated Ticket Volume: _________________per Day (                        ) Week (   ) Month ( )
                                                                 Other (    ) specify_____________________
Deliver equipment to: Bursar’s Office, Deal Hall-Rm1028, Attn: Lyn Deal


                                     REQUIRED APPROVALS

  Department Head:           ______________________________(signature) Date:____________

  Internal Audit:            ______________________________(signature) Date: ___________

  Bursar’s Office:           ______________________________(signature) Date: ___________

  IT Services:               ______________________________(signature) Date: ___________
**Last signature above forwards to Procurement & Contract Services, PO Box 8123
Note: All questions/inquiries regarding credit card machines or acceptance of credit card software should be
directed to the Director (Bursar’s Office). This will apply to new, replacement or reprogrammed machines


After obtaining required approvals, fax completed form to:       BB&T
                                                                 Attn: Christy Bergmann, Merchant Services
                                                                 912-790-3393 (fax)
                                                                 912-790-3395 (phone)

Banking Institution will contact the using department to determine equipment needs and provide a price
quote (approx $500.00). Department will forward price quote to Procurement and Contract Services, PO Box
8123 for signature. Once signed, Procurement and Contract Services will fax to BB&T. Department will
email Kathy Rushing, Financial Accounting with the following info: speed chart/account code and contact
person with phone/fax/email info.



Revised: 2/3/09