Fillable 2018 Dept Request For Auth-Self-Assessment

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2018 Dept Request For Auth-Self-Assessment

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File type: PDF

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Reviewed September, 2018
Request for Authorization to Accept Credit Card Transactions
Department Name:
Program/Area to Accept Transactions:
Primary Contact:
Phone Number:
NOTE: Cardholder Data is defined as the entire Personal Account Number (full credit
card number) plus either the corresponding expiration date, cardholder name and/or service
code. As Cardholder Data is classified as extremely sensitive information, we are required to
keep it secure and safeguarded at all times.
The last four digits of the credit card number may be maintained for reference and do not
constitute cardholder data.
I. Provide a description of your planned activities for which you will be collecting credit
card payments:
II. Describe how and in what capacity y
ou will process, transmit and/or store
Cardholder Data:
III. Our department plans to accept credit/debit cards (check all that apply):
☐ By email
☐ In person
☐ By phone
☐ By mail
☐ By fax
☐ Online payments entered by customer into UWF’s system
☐ Other:
Reviewed September, 2018
IV. Type of equipment to be used to process credit card transactions:
☐ Card swipe terminal connected directly to bank
☐ Personal Computer
☐ Other (provide description):
V. Types of records that will be created containing Cardholder Data:
☐ Paper receipts
☐ Other paper documents (provide description):
☐ Electronic files (provide description):
VI. Person responsible for record s
ecurity and inventory maintenance:
VII. Outside entity to be used to process credit card transactions.
a. Name of processing company:
b. Name of system or software to be used:
Reviewed September, 2018
List all people in your department that will have access to Cardholder Data:
Name
Title
Reviewed September, 2018
Certification:
I confirm that my department understands and will comply with the University’s procedures related to
accepting credit/debit card transactions and the safeguarding of Cardholder Data. I understand that the
University is contractually required to comply with the Payment Card Industry - Data Security Standards,
and any unauthorized disclosure or breach of Cardholder Data may subject the University to severe fines
and penalties.
Signatures:
Date:
Primary Contact:
Dept. Chair/ Director:
Date:
Attach additional
information that you feel will assist us in understanding your request. Please return
completed form to Office of Compliance and Ethics, Bldg. 20-W/ Rm. 158A.
Questions/ Concerns:
Matt Packard, CCEP
Chief Compliance Officer
850.857.6070 | mpackard@uwf.edu
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2018 Dept Request For Auth-Self-Assessment

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Completed 13 February 2020

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