UHS Credit Card Merchant Request Form

Merchant Description Campus Department

Business name on sales receipt Merchant ID Need ID? No
Description of business activity

Merchant Location
Street Address for Location 1 Action: N/A
Street Address for Location 2 N/A
Street Address for Location 3 N/A

Merchant Contacts
Primary Contact Action: N/A Name Phone
Email Fax
Secondary Contact Action: N/A Name Phone
Email Fax

Credit Cards Accepted Action: N/A Visa

N/A MasterCard
N/A Discover
N/A American Express

Equipment/Software Used Action: N/A POS Terminal

N/A Payment Collection Gateway Virtural Terminal
N/A Payment Collection Gateway
N/A First Data PayEzee Gateway
N/A Other third-party software
N/A Other third-party equipment
Description of third-party
software/equipment.

Certification of Person Primarily Responsible for Overseeing Merchant Credit Card Activities
1. I will require all staff that process credit card transactions, have access to sensitive credit card information, process credit card journal entries,
or supervise these employees to take the appropriate credit card training before performing credit card related tasks and annually thereafter for as
long as they continue to perform these tasks.
2. I have completed the PCI Questionnaire for UHS Merchants and will take any steps necessary to comply with security requirements indicated
by the component PCI compliance representative, Information Technology, and Treasury.
3. I will promptly report any suspected compromise of cardholder data to Bank of America, the Treasuer's Office, the Information Security
Office, and Internal Audit.
4. I will notify the Treasurer’s Office when I am no longer the person(s) responsible for overseeing credit card activity for my unit or when my
unit no longer needs to accept credit cards.

Responsible Person/Requester (sign above) Date Phone Fax Email

Unit Head Approval (sign above if approved) Date Phone Fax Email

Component IT and System IT Review Required? NO

Approved? (circle "yes" or "no") Yes No

Component IT (sign above when reviewed) Date

Approved? (circle "yes" or "no") Yes No

Component PCI Rep (sign above when reviewed) Date

Approved? (circle "yes" or "no") Yes No

System IT (sign above when reviewed) Date

Approved? (circle "yes" or "no") Yes No

Treasury Official (sign above when reviewed) Date

Form revised May 10, 2016 1 of 1