REQUEST TO ACCEPT CREDIT CARDS – TERMINALS ONLY
Please TYPE all information below except for signatures
MERCHANT INFORMATION
Department Name:
DBA Name (Name to appear on cardholder statement):
Customer Service Phone Number (to appear on cardholder statement):
Fax:
Mailbox Number:
Physical Address (Required):
Address Line 2:
City:
State:
ZIP Code:
CONTACT INFORMATION
Merchant Contact Name:
Phone:
E-mail:
Mailbox Number:
ACCOUNT INFORMATION
Accept American Express?
YES
NO
What are you accepting payments for?
Estimated Average Ticket Value:
Estimated Monthly Transaction Volume:
TERMINAL INFORMATION (PLUG-IN)
If this is a Mobile/Wireless request, please leave this section blank
Purchase Type:
RENT
Processing Type:
PURCHASE
DIAL-UP
ETHERNET
Number of Terminals to Rent or Purchase:
MOBILE/WIRELESS PROCESSING
If this is a Plug-In Terminal request, please leave this section blank
Processing Method:
Wireless Terminal(s)
If Terminal, Purchase Type:
RENT
Virtual Merchant Mobile
PURCHASE
If Terminal, Number of Terminals to Rent or Purchase:
ACCOUNTING INFORMATION (REQUIRED)
Budget Name:
Budget Number:
Revenue Code:
AUTHORIZATION
By signing below I certify that I have read APS 35.1 C o m p l i a n c e P o l i c y f o r P a y m e n t C a r d I n d u s t r y
S e c u r i t y S t a n d a r d s and am aware of the initial and ongoing responsibilities required as a Merchant
Contract Holder including annual completion of the PCI Self-Assessment Questionnaire (SAQ).
Requesting User (Printed Name):
Name of Department/College/Other:
Signature:
Date:
Chair/Dean/Director (Printed Name):
Name of Department/College/Other:
Signature:
Date:
* Requests will NOT be processed without a Chair/Dean/Director Signature
Please Return Form To: Jen Kroleski
Via Email: jkrolesk@uw.edu
Via Campus Mail: Box 355820. Schmitz Hall 550
Via Fax: 206-685-2942