Merchant Account Statement Templates - PDF

							Johns Hopkins University                                                                             Print Form          Submit by Email

Office of the Treasurer                                                   Visa/MC
Suite C-020
1101 E 33rd Street                                                        Discover
Baltimore, Maryland 21218
(P)443-997-8120 (F)443-997-4188                                           Amex


 Request for Merchant Account                                                       Date Submited

 Department Information
 You must complete all fields marked with *
                                                                           * Contact Name
 * Department Name
                                                                           * Contact E Mail
 * Division/School                                                         * Contact Phone

                                                                           * Contact Fax


  Account Information
   Name of Account
                          (Please enter the name as it should appear on the merchant statement)

   Name to Appear on Customer's Credit Card Statement

   Business Type (please choose one)
         Tuition                  Donations                 Co Payments               Retail                 Other
   Mailing Address
      Name
      Address
      City                                                     State                      Zip Code
      Suite/Room
   Location Address               Same as Mailing Address

      Name

      Address

      City                                                     State                      Zip Code

      Suite/Room
  Type of Cards Accepted (please check the cards you wish to accept)

             Visa/Master Card                                   Discover                                     American Express

 Note: Visa/Master Card require 10 day set up, if you require faster set up time there is a $75 charge for rush set up.

     Please check if you need Rush Set up                         RUSH setup
 Method of payment processing

      Computer/Card Swipe/VPOS                   Internet Buy Page (Chase)                  Internet/PayPal(Verisign)
       Accounting Information
       Revenue Codes       Please list the codes most frenquently used (you may list up to 10)

                Cost Center/Internal Order                         Fund                           SAP G/L
          1.                                      1.                                        1.

          2.                                      2.                                        2.

          3.                                      3.                                        3.

          4.                                      4.                                        4.

          5.                                      5.                                        5.

          6.                                      6.                                        6.

          7.                                      7.                                        7.

          8.                                      8.                                        8.

          9.                                      9.                                        9.

          10.                                     10.                                       10.

       Expense Code Please list the code for fees associated with this account
             Cost Center/Internal Order                         Fund                              SAP G/L

          *                                        *                                         *

       Revenue Information

         Estimated number of credit card transactions per month


        Estimated average ticket


        Estimated average monthly dollar volume




Manager/Supervisior Authorization

  Manager Phone Numer                                                      Date Requested


  Manager Name

  Manager E Mail

NOTE: Please submit this form by clicking on the Submit by E mail button or printing out a copy and faxing it to
                                  the Office of the Treasurer 443-997-4188

                Please contact the Office of the Treasurer at treasuryops@jhu.edu for any questions.