THE OHIO STATE UNIVERSITY OFFICE OF THE TREASURER
Credit Card Merchant Agreement and Request Form
A. MERCHANT NAME:
The merchant name will print on customers’ receipts (up to 24
characters) Internet accounts
– please note that the department
phone number will print on the receipt.
C1. CONTACT NAME:
C2. CONTACT e-MAIL ADDRESS:
C3. PHONE #:
C4. FAX #:
B. DATE:
E. INVOICE ADDRESS: (please print full address)
Business Name:
Street Address
City, State, Zip:
F. OUTLET & SHIP TO ADDRESS (if different from invoice)
Business Name:
Street Address:
City, State, Zip:
G. INDICATE METHODS USED BY YOUR DEPARTMENT
H. INFORMATION ABOUT YOUR BUSINESS
1. Approximate annual credit card sales volume:
2. Average $ Sales Ticket:
3. Services or product you sell?
4. Seasonal Business: Yes
No
5. If seasonal, indicate months business is open:
TO PROCESS CREDIT CARD TRANSACTIONS:
Accepting credit card payments through an internet website
Using a terminal connected to a data phone line
Using a terminal connected to a computer
Using Point of Sale Software
Sending or batching credit card information via the internet
Using any third party software related to credit card payments
Using wireless
/
/
Person responsible for reconciliation of the account:
D1. ACCOUNTING CONTACT NAME:
D2. ACCT. CONTACT e-MAIL ADDRESS:
D3. ACCOUNTING PHONE #:
Jan Feb Mar Apr May June July Aug
Sep Oct
Nov Dec
I. IS YOUR CREDIT CARD PROCESSING PART OF THE
FOLLOWING DEPARTMENTS:
Student Affairs
Athletics
Transportation & Parking
Physician Office
J. CREDIT CARDS ACCEPTED: Yes No
Visa/Master Card
Discover
American Express
K. ORDER CREDIT CARD TERMINAL CONNECTED TO
A DATA PHONE LINE? If yes, complete the following:
a. If processing Buck ID and credit cards, order a dual processing
terminal from Buck ID
a. If using an existing terminal, indicate Manufacturer’s
Name and terminal number:
b. Indicate number of terminals ordered:
c. Indicate purchase or rental: Purchase $549
Rent $55mo
d. Type of terminal:
e. Indicate % type of terminal transactions (should total 100%):
Swipe:
Mail Order/Keyed:
Phone order/keyed:
L. INTERNET, THIRD PARTY PROCESSING, POS
SYSTEMS, or WIRELESS
a. Is your department redirecting the transmission and storage
of credit card data to a third party PCI service provider:
(1) Internet Service Provider:
(2) Service Provider’s product name:
(3) Website Address:
b.Is your department using PCI Approved Software or Wireless
(1) Software/Wireless Name
(2) Internet Service Provider:
(3) Website Address (unless using wireless):
M. CHARTFIELD INFORMATION:
1. FEES: Org:
Fund:
Account: 63633 (for University Merchant Fees)
Account: 76566 (for Medical Center Merchant Fees)
N. MERCHANT AGREEMENT:
I have read The Ohio State University Credit Card Merchant
Policy and agree to the responsibilities, policies, and procedures
established by the Treasurer’s office. I understand it is my
responsibility to supervise the activity of credit card handlers and
report to the Treasurer’s office in writing any breach of credit
card information and to immediately remedy such breach. I also
agree to communicate the Payment Card Industry (PCI) policies
to my staff and perform an annual self-assessment. Further, if
processing internet transactions, I agree to perform or supervise
the required system scans and assessment.
Signature Fiscal Officer
Print Name of Fiscal Officer
2. REVENUE: Org:
Fund:
Account: (for deposits)
For Treasurer’s Office Use:
Notify Bank Reconciliation, Accounting & Department
Visa/MC #: __________________________________
Discover#:___________________________________
AmEx #: _____________________________________
THE OHIO STATE UNIVERSITY OFFICE OF THE TREASURER
Credit Card Merchant - Items of Importance:
1. Phone Line - A dedicated phone line is required for terminal transactions. Complete an OSU Requisition with
the following information:
Heading/subject on requisition: for VISA verification line
a. Modem line
b. Direct Inward dial
c. Unrestricted
d. Building and room number
e. Jack number if available
Send request to UNITS. This request must be done 10 working days prior to the desired start date.
2. Terminal Costs - The cost of a standard new terminal with printer is $549.00 for a Hypercom . Monthly
rentals are available for $55 per month.
3. Internet, Wireless, Service Providers and Software – Please check with the Treasurer’s Office and the
University’s Credit Card Policy regarding use of PCI (Payment Card Industry) approved Third Party Service
Providers, Wireless, Internet, and use of Software for processing credit card transactions.
4. Internet Fees - If using the internet, check with your PCI approved internet provider for fees.
5. Credit Card Fees - Merchant Fees will be assessed each month based on your total monthly sales. The
approximate charges are as follows:
(Rates are subject to change when Visa and MasterCard publish the new Interchange Rates in April and October)
a1.Visa: 1.43% plus $0.05 per item, plus.0925% Assessment fee, plus $0.05 per item Huntington
Merchant Services fee.
a2. If using internet – 1.85% plus $0.10 per item, plus .0925% Assessment fee, plus $0.05 per item
Huntington Merchant Services fee.
b1. MasterCard: If swiping card - 1.64% plus $0.10 per item, plus .095% Assessment fee, plus $0.05 per
item Huntington Merchant Services fee.
b2. If keying card – 1.95% plus $0.10 per item, plus .095% Assessment fee, plus $0.05 per item
Huntington Merchant Services fee.
b3. If using internet – 1.95% plus $0.10 per item, plus .095% Assessment fee, plus $0.05 per item
Huntington Merchant Services fee.
c. American Express charges are 2.6% for retail and 3.15% for internet, plus $0.05 per item
Huntington Merchant Services fee.
d. Discover charges are 1.65% for keyed, swiped or Internet, plus $0.05 per item Huntington Merchant
Services fee.
6. Buck I.D. - Contact David Anthony at 2-7240 to order a dual processing terminal to process credit cards and
Buck ID. You must request a Tranz 380 x 2 and printer.
7. Questions - If you have any questions, call Carole Fallon at 292-7792. Send completed form to:
Mail: Carole R. Fallon, Treasury Management Officer, Office of the Treasurer, Riverwatch Tower,
Suite B, 364 W. Lane Avenue
Fax #: 292-7568
e-mail: fallon.82@osu.edu