Please complete the application online then print for signatures. Please submit completed form to the Bursar via campus mail or electronically to . Application Type: Merchant Account Name (if existing) Name: Email Address: Department: Ext: Fax: Explain why your department wants to accept credit card payments. Frequency of Payments: Provide a list of the goods and/or services which you are requesting to add/modify. If this is a new source of revenue for your department, please contact the Office of the Controller for assistance. Attach Page 2 if you have additional revenue sources. Change Item to be purchased with card Account number including object code Will your department accept the following credit card methods for the goods and/or services listed above? If so, please indicate the estimated annual dollar volume and number of transactions for each credit card acceptance process: Type of Transaction Accepted Payment Method Annual Dollar Amount Number of Transactions In-person Internet/Online Primary Department Manager: Job Title: Ext: Secondary Department Manager: Job Title: Ext: This is an optional additional account manager. Please identify any additional staff who will be involved in processing credit card payments. Include name, job title, phone extension, and date that the cash handling training was completed. Attach Page 2 if you have additional employees. Date of Cash Change Employee Name Job Title Ext. Handling Training Will any 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. Have you obtained copies or accessed the online version of the applicable Credit Card Acceptance and Security Policy for Accepting Credit Card and electronic payments? (If no, contact the Bursar’s by emailing ) Have all staff who will be involved in processing credit card payments been made aware of and had access to these documents? (If no, contact the Bursar’s by emailing ) By signing this form, the Department Head and Primary Contact acknowledge that they understand the TWU Credit Card Acceptance and Security Policy and the importance of their roles and responsibilities for maintaining compliance within their department. By signing this form, the Department Head approves of the business case presented for the department to accept credit card or electronic payments. Department Head Signature Department Head Printed Name Date Primary Contact Signature Primary Contact Printed Name Date
Please complete the application online then print for signatures. Please submit completed form to the Bursar via campus mail or electronically to . Application Type: Merchant Account Name (if existing) Name: Email Address: Department: Ext: Fax: Explain why your department wants to accept credit card payments. Frequency of Payments: Provide a list of the goods and/or services which you are requesting to add/modify. If this is a new source of revenue for your department, please contact the Office of the Controller for assistance. Attach Page 2 if you have additional revenue sources. Change Item to be purchased with card Account number including object code Will your department accept the following credit card methods for the goods and/or services listed above? If so, please indicate the estimated annual dollar volume and number of transactions for each credit card acceptance process: Type of Transaction Accepted Payment Method Annual Dollar Amount Number of Transactions In-person Internet/Online Primary Department Manager: Job Title: Ext: Secondary Department Manager: Job Title: Ext: This is an optional additional account manager. Please identify any additional staff who will be involved in processing credit card payments. Include name, job title, phone extension, and date that the cash handling training was completed. Attach Page 2 if you have additional employees. Change Employee Name Job Title Ext. Date of Cash Handling Training Will any 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. Have you obtained copies or accessed the online version of the applicable Credit Card Acceptance and Security Policy for Accepting Credit Card and electronic payments? (If no, contact the Bursar’s by emailing ) Have all staff who will be involved in processing credit card payments been made aware of and had access to these documents? (If no, contact the Bursar’s by emailing ) By signing this form, the Department Head and Primary Contact acknowledge that they understand the TWU Credit Card Acceptance and Security Policy and the importance of their roles and responsibilities for maintaining compliance within their department. By signing this form, the Department Head approves of the business case presented for the department to accept credit card or electronic payments. Department Head Signature Department Head Printed Name Date Primary Contact Signature Primary Contact Printed Name Date
Credit-Card-Applicaiton_2014_03_06.docx