Fillable Merchant Services Request Form (Saint Louis University)

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Merchant Services Request Form (Saint Louis University)

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New Merchant Application Form - January 2016 Page 1 Page 1
MERCHANT SERVICES ACCOUNT REQUEST/MAINTENANCE FORM
Saint Louis University
New Merchant
Existing Merchant, New Payment Process/Application
Update Merchant Manager or Contact Information
Close Merchant Account
TRANSACTION DETAILS
Anticipated Frequency of Card Activity:
Projected Annual Sales ($):
CUSTOMER RECEIPT DETAILS
Business Name:
Phone Number:
Address:
PROCESSING DEVICE
Point Of Sale (POS) Terminal
Terminals are provided through our
Merch
ant bank. Anticipate 6-8
weeks for setup and delivery. See
page 2 for pricing.
# of Terminals Requested:
UPay Site
E-COMMERCE
SLUCare Use Only
Customer ID Number:
Department Contact Name:
Request New Terminal
Request E-Commerce - SLU Marketplace Site
Request U-Pay Site
Request Third Party Vendor/Terminal Set-Up
Select One
Wireless Point of Sale (POS) Terminal
Wireless terminals transmit credit
card data through a cellular network.
Anticipate 6-8 weeks for setup and
delivery. See page 2 for pricing.
Third Party Terminal
University preferred payment
gateway for use with University
Websites or Third Party Vendors
E-Commerce Marketplace
E-Commerce Third Party Vendor
Contract with Vendor must include PCI language and must be approved by
the PCI Compliance Committee.
Name of Vendor:
Does the vendor require a payment gateway?
Is the vendor PCI compliant?
Please copy/paste the link below into your browser to complete the
form required for a SLU Marketplace Store Request.
http://www.slu.edu/busfin/departments/treasury-and-investments/credit-cards-
and-e-commerce/marketplace/marketplace-store-request
NO
Number of Terminals Requested:
E-Commerce Site Requested:
NO
NO
# of Terminals Requested:
Third party terminals are required by a
third party vendor.
Name of Vendor:
# of Terminals Requested:
New Merchant Application Form - January 2016 Page 2
PAYMENT APPLICATION
Describe the type of business
activity that requires merchant
processing:
Select all methods in which credit
cards will be processed:
Types of Credit Cards to Accept
Visa / MasterCard
Discover
American Express
Banner Fund & Account to be Billed:
Name o
f Fund/Account to be Billed:
POS
Wireless
3rd Party
Terminal
E-Commerce
3rd Party
E-Commerce
Marketplace
UPay Site
Merchant Managers are responsible for the management of all aspects of
merchant card processing related to their respective merchant. This includes
compliance with all applicable policies and procedures as listed below, as well as
oversight of all employees who handle or process credit card data. Managers
are required to take the SLU PCI Compliance Training prior to the approval of any
new merchant account or processing. This excludes those Merchant Managers who
have already completed the training within the past year.
Merchant Manager Name:
Merchant Manager Office Address:
Phone Number:
E-Mail:
List all individuals within your department, including student workers,
that handle credit card data:
Standard Pricing for Terminals:
FD130 Terminal with PIN Pad $629.00
FD410 Wireless Terminal $849.00
Standard Fees:
Wireless Fee $16.00 per month
Standard Terminal Fee $5.00 per month
Marketplace Fee: 2.25% of monthly total revenue
Processing Fees $.10 per transaction + M/C/Visa/Discover/AMEX
Interchange/Assessment Fees 2% - 3%
Please note that these prices are subject to change. For a
more detailed breakdown of services and fees, please
email merchantservices@slu.edu
Training for PCI Compliance must be completed by all employees that
accept or will accept credit cards. For any questions, please contact
Katelyn Willman at 314-977-2221 or merchantservices@slu.edu
APPROVALS
Merchant Manager Date
Department Head Date
Dean/Vice President Date
PCI Compliance Committee Date
Fund:
Account:
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Completed 23 July 2020

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