Payment Card Service - Department Request to Process Credit Cards Form

Departmental Request to Process Credit Cards

Please fill in all boxes and then print this form. Gather the appropriate signatures and then mail to the address below.

Department:
Mailing Address:
Campus Address:
Primary Contact:			Telephone:
Email Address:			Fax:
Alternate Contact:			Telephone:
Email Address:			Fax:
IU FIS Account for Deposits/Income:			Object Code:
IU FIS Account for Fees/Expense:			Object Code:
Estimated Annual Credit Card Sales Volume:
Estimated Credit Card Average Sale Amount:
Percent of Credit Card Sales:	Over the Counter		Telephone/Mail
Optional Cards (Visa/MasterCard/Discover automatic): American Express
Anticipated Number of Terminals Needed:
*NOTE: Each Terminal will need a shared or dedicated analog phone line installed by Communications.
Debit Card Pin Pads Needed:
Cash Register Interface with Credit Cards?		Yes No
*NOTE: You must send the software specifications for your cash register system with this form to verify compatibility with existing credit card software.
Departmental Services Offered by Accepting Credit Cards:

Fiscal Officer Signature:_______________________________________________ Date:__________________

Campus Administrator Signature:_______________________________________ Date:__________________

Please return completed form to:
Payment Card Services
Treasury Operations
400 E. 7th Street Poplars Building - Room 205
Bloomington, IN 47405-3085
812-855-0586/FAX 812-856-5821