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 email@example.com for any questions.
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