Application for Acceptance of Credit Cards by Uva Departments

Application for acceptance of Credit Cards by UVa Departments

Department Name: ______

Physical Address : ______

UVa mailing address: ______

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Individual responsible for the Credit Card Project: ______

Phone Number:______Fax Number:______

Email address: ______

The above listed individual has read and fully understands Financial Administration Policy V.A.1 and Procedure 15-70 regarding approved revenue generating activity and acknowledged that the products, fees and/or services the department is engaged in selling are in full compliance with the Policy and Procedure. ______

Signature

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·  Describe in detail the products, fees and/or services that are being offered for sale.

·  For a Conference, meeting or event, is this a single occurrence or will the events reoccur?

ONE TIME / ON GOING

Please indicate the period of time the account should be available for processing charges. (include an additional 60 days at the end to allow for credits and/or disputes)

From ______Until ______

·  Method the department/unit will use to accept Credit Cards: (check all that apply)

___X_ in person or mail/telephone order _____ mail order/telephone (PC with software)

(swipe terminal) OPTION II

_____Web (UVA Gateway to NOVA) _____in person Cash Register with swipe

OPTION I capabilities OPTION II

_____ Web (other software) OPTION II

·  If Web, please list the URL. ______.

·  Does the department/unit currently make deposits directly into Bank of America? Yes / No

·  If yes, please indicate the bank account number. ______

·  If the revenue is not deposited into a University Bank account at Bank of America, please

explain in detail where the funds are applied and on what authority. ______

______

______

·  Indicate the name, phone and email for the individual responsible for entering the credit

card deposit information into Oracle.______

·  Indicate the Oracle PTAEO number to be used to charge the Discount Fees, Chargebacks

and other processing costs to______

·  Org. Code the Department will use to record revenue if different from the Org used in the

PTAEO above ______

·  Please estimate the anticipated average sale (______), the annual sales

volume (______) and indicated whether your sales are seasonal

and describe. ______

·  Date the department/unit would like to begin accepting credit cards.______

(This date must be a minimum of 30 days from the date the application is submitted.)

·  Description the department would like to appear on the cardholder’s statement (25 character limit).

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·  Name, phone number and email of Contact person within the Department who will

oversee the front end Credit Card processing and Credit Card statement review and

reconciliation if different from the Revenue Project Manager. ______

______

·  Name, Phone number and Email of the individual responsible for Chargebacks

(cardholder disputed transactions). ______

·  Please list the name and model number of the swipe terminal or Cash Register system currently in use.______

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For Revenue and Collection’s Use Only

Date application received ______

Approved ______

(signature and date)

Date MID requested ______

Merchant Number ______ViaKlix Number ______

Date Activated on Gateway. ______

Discover Number Requested ______Discover Number ______

MERCHANT OPTIONS

OPTION I – WEB UVA GATEWAY Please indicate name, phone number and email for the individual who developed the WEB site and provides programming support to maintain the Web site and who will be available to make the necessary changes to plug into the NOVA?ViaKlix Gateway.

______

OPTION II - If the department/unit will be using software purchases from an outside vendor or developed internally that bypasses the UVA Gateway or performs front-end processing (cash register, PC or WEB), please indicate the name of the package, the manufacturer, the contact individual, the address and phone number. (See Note) ______

NOTE: See Payment Card Industry Data Security Standards (attached), section 12.8.1 through 12.8.5 concerning the contractual requirements for all third party vendors to be PCI compliant. You must provide documentation from the software vendor or provider that certifies PCI compliance and be willing to have the software periodically scrutinized by UVA’s IT Director of Communications and Systems and all external-facing IP addresses scanned by an outside vendor for system vulnerabilities.

Indicate agreement by signing: ______

Name: ______

Title: ______