Accounts Receivable AR04
Purpose of Form: The Finance Department keeps track of the Merchant ID and Point-of-Sale (POS) terminals, and should be
informed of any closures of Merchant IDs and/or returns of unused POS terminals. This will ensure that departments are not
being charged additional equipment and bank fees for any inactive Merchant IDs and unused POS terminals. Please use this
form for when you wish to close a Merchant ID and/or return unused POS terminals.
1. Requestor Information:
Name: _________________________________ Ext: ______ Email: _______________________
Department: ____________________________
2. Merchant ID & Machine Information:
> Merchant ID: _____________________
> Do you want your Merchant ID to be closed by Finance Department? Yes No
> Please enter the number of machines you are returning: _____
> Please select the type of machine you are returning:
> If ‘Other’ is selected above, please specify: __________________________________
3. Authorization:
Your typed name below indicates your approval of the form and confirms that all information is accurate.
Name: _____________________________________ Date: _________________
Department: ________________________________
Once completed, please submit this form to Accounts Receivable / Finance Department: If there are any questions while filling out the form, please contact: Dannielle
Quenneville by phone at ext. 2125 or by email at
Approved by: _____________________ Date: __________________
Comments: _______________________________________________________________________________
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