UNIVERSITY OF TEXAS AT DALLAS
APPLICATION TO BECOME A MERCHANT DEPARTMENT
P l l e a s e c o m p l l e t t e t h e a p p l l i i c a t t i i o n o n l i n e t t h e n p r i n t f f o r r s i g n a t t u r e s .
___________________________________________________________________________
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Date Submitted: (Please allow 2 weeks for processing) :
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Name:
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Title:
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Department and School/Division :
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Email Address :
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Phone Number :
___________________________________________________________________________
1.
Please explain why your department wants to accept credit card payments. Include a description of the goods and/or services for which you will receive payments.
Please be specific:
2. Describe the economic benefits that you expect to gain by accepting credit cards.
( You may attach additional documentation to support this application.)
3. Describe the frequency of credit card payments. Is this a one-time event? Are payments for seasonal or year-round activity? Provide detailed timeframes .
4. Is this an existing or new source of revenue?
5. Please provide the PeopleSoft cost center and account code where revenue will be recorded. Note : Credit card fees will be 2-2.5% of your projected sales and will be posted to the cost center you indicate below and account code 63032. Please budget for these fees.
Cost center Account code
UTD Merchant Department Application page 1 of 5

6. What other methods of payment do you anticipate accepting for this specific purpose? (Check all that apply ~ double click on box to check)
X Credit Card/Electronic Payments Electronic Checks
Cash/Paper Checks (Cash handling procedures and training is required.)
7. How do you plan to process these payments?
In-person (card present) Internet
If Phone/Fax order, please explain:
Phone/Fax order*
*Note: For security reasons, faxes must be secured. Revenue collection arrangements that require payees to enter credit card numbers on preprinted order forms which are then mailed to a UTD department are not allowed. Credit card data should never be transmitted via email correspondence.
8. Please indicate the estimated number of transactions and annual sales and for each
applicable credit card transaction type. (Example: For an estimated 100 transactions in one year at $25 each, the annual sales would be $2,500).
Estimated sales per year
Transaction Type
Example: Internet
# of transactions
per year
100
$ Amount per transaction
25
Estimated
Annual Sales
$ 2,500.00
Internet
In-person
( Written cash handling procedures required)
Phone/Fax *
Total -
0 $ -
0
0
$ -
$ -
$ -
-
-
-
$ -
(Double-click table above to edit)
Merchant Department Application page 2 of 5

9. Who will be the Merchant Department Representative (MDR) and additional users?
The MDR, as referenced in the UTD Policy for Accepting Credit Card and electronic payments, is responsible for managing credit card and/or electronic
payment transaction processing. Include name, job title, Net ID, phone extension and user role below.
Name Title Net ID Phone # User Role (from list below)
User Role Responsibilities
*Manage their merchant's settings
Merchant Department
Representative or Merchant
Manager
*Manage credit card and/or electric payment transaction process
*Review Marketplace financial reports
Store Manager
* Designate store clerk, store contact, fulfiller with refund/cancel rights, and fulfiller users
* Review Store Revenue reports by Product, Stock Numbers, Product Type, and Totals
Store Contact
Fulfiller with Refund/Cancel
Rights
Fulfiller
This is the designated contact that appears on the store site via the
"Contact Us" link in the bottom navigation bar. The user assigned the store contact role must add their e-mail address to their user profile.
The store contact's email address appears in automatically generated order confirmation e-mails sent to buyers.
* Fulfill orders
* Refund orders
* Cancel orders
Fulfill orders
Store Accountant View reports. Store accountants cannot make any changes to store settings.
Merchant Department Application page 3 of 5

Card Acceptance Guide and Operating Regulations and Rules:
10. Have you obtained copies of the applicable Card Acceptance Guide(s) and
Operating Regulations and Rules as referenced in the UTD Policy for Accepting
Credit Card and Electronic Payments?
Yes No
11. Have all staff who will be involved in processing credit card payments been made aware of and have access to these documents?
Yes No
Web Based Storefront:
12. If you are planning to accept credit card payments via the Internet, do you have a
Marketplace website?
If so, please provide the Storefront name and the URL : a.
Name: b.
URL:
13. If you are requesting a Marketplace website, please answer the following: a.
What information do you need to collect from each customer?
(Name, Address, and Email are collected by default) b.
Do you have a description and images for each product? c.
Do you have prices for each product?
14. What is your return policy? ( Required )
15. Will any other departments, software packages or outside vendors be involved in the processing of credit card payments? If so, please identify all parties and describe their roles and responsibilities.
Yes
No
Roles/Responsibilities:
Merchant Department Application page 4 of 5

Request for Alternate Vendors: Please complete Appendix - I
Please complete Appendix I if submitting a request the use of an alternate vendor.
Signatures:
Signatures: ______________________________ __________________________
Merchant Dept Representative Department Head
Printed names:
By signing this form, the Merchant Department Representative acknowledges that he/she understands his/her role as outlined in the “UTD Policy for Accepting Credit Card and electronic payments” and accepts the responsibility of that role.
By signing this form, the Department Head approves of the business case presented for the department to become a Merchant Department, the information provided and the designated
Merchant Department Representative.
Please submit completed form to the Treasury via email at FMS_Treasury@utdallas.edu
, or via campus mail: Administration Building, AD37.
___________________________________________________________________________
Reviewed By: ___________________________________ Date: _________________
Treasury & State Accounting Manager
Approved By: ___________________________________ Date: _________________
Associate Controller of Finance - Operating
Merchant Department Application page 5 of 5