CALIFORNIA STATE UNIVERSITY CHICO
FINANCIAL SERVICES
STUDENT FINANCIAL SERVICES
STUDENT SERVICES CTR RM 230
CHICO, CA 95929-0242
530-898-5936
www.csuchico.edu/sn
SFIN: Credit Card Channel Request Form Updated June 2015
SIGNATURE PRINT NAME DATE
SIGNATURE PRINT NAME DATE
(explain reason)
SIGNATURE PRINT NAME DATE
IRRRequesto Info mat on
Division/Department Name:
Financial Account Location (University, Auxiliary Organization):
Merchant ID, if known:
Business Unit Functional Contact:
Title:
Telephone:
Responsible Administrator:
Title:
Telephone:
Credit Card Channel
Request Form
CSU Policy ICSUAM 3102.5 requires that the campus CFO or designee approve all physical locations, websites, 3
rd
party
processors, or any channel accepting credit card payments by the university.
Please note that no funds should be collected until you have received notication from the Director of Student Financial
Services that your department is approved.
Send completed form to Student Financial Services (SSC 230 – Zip 242) for review. Before your request is nalized, it will
be necessary to complete a CSU, Chico Credit Card Business Process Inventory form with the Information Security Ofce.
IRIDesc pt on of Request
Briey describe why your business unit is requesting to accept credit cards, what are your customers
obtaining with their credit cards and what is your department’s role in the payment process:
It is the responsibility of the Responsible Administrator to ensure compliance with the campus guidelines for accepting credit cards. Failure to comply with
the university guidelines and requirements of the Payment Card Industry Data Security Standard will risk a department’s approval to accept credit card
payments. Read the CSU, Chico Payment Card Industry Data Security Standards compliance requirements and determine the department obligations.
IRIautho zat on
Business Unit Functional Contact:
Responsible Administrator:
Student Financial Services:
Approved Denied
