Fillable Dept Request For Authorization

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Dept Request For Authorization

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File type: PDF

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University of West Florida
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 (credit card
number) plus corresponding expiration date, cardholder name and/or service code.
Cardholder Data is extremely sensitive information and should be kept 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.
Provide a description of your planned activities for which you will be collecting credit
card payments:
Describe how and in what capacity you will process, transmit and/or store Cardholder
Data:
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 – describe _____________________________________________
Page 2 of 2
Type of equipment to be used to process credit card transactions:
____ Card swipe terminal connected directly to bank
____ Personal Computer
____ Other – describe _____________________________________________
Types of records that will be created containing Cardholder Data:
____ Paper receipts
____ Other paper documents – describe _______________________________
____ Electronic files – describe ______________________________________
Person responsible for record security and inventory maintenance ___________________
Outside entity to be used to process credit card transactions:
____ Name of processing company ___________________________________
____ Name of system or software to be used ____________________________
List all people in your department that will have access to Cardholder Data:
Name Title
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________
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:
Primary Contact __________________________________ Date _____________
Department Chair/Director ____________________________ Date ______________
Attach additional information that you feel will assist us in understanding your request.
Please return completed form to Financial Services, Bldg. 20-E. Questions call 474-3028.
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Dept Request For Authorization

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Completed 12 February 2020

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