Form As537-Credit Card Merchant Agreement And Request June 2016
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1Louisiana State University
Office of Accounting Services
Bursar Operations
125 Thomas Boyd Hall
CREDIT CARD MERCHANT AGREEMENT AND REQUEST
AS537
Merchant Name
(will print on customer’s receipt and statement;
24 character limit on name)
Contact Name
Phone
Fax
E-mail
Person responsible for PCI Compliance & Annual Assessment
Name
Phone
E-mail
Person responsible for Account Reconciliation
Name
Phone
E-mail
Driving Worktag:
Spend Category:
Ledger Account:
Merchant Address (print full address)
Ship to Address (if different from Merchant Address)
Business Name
Business Name
Address
Address
City, State, Zip
City, State, Zip
A.
Indicate methods to process credit card transactions:
Accepting credit card payments through an Internet website
Using a terminal connected to a data phone line
Using a terminal connected to a computer
Using Point of Sale software
Sending credit card transactions via the Internet
Using third party software
Using wireless
B.
Information about your business:
1.
Approximate annual credit card sales volume: ________________
Estimated Average Ticket Amount: ____________
2.
Services or product you sell? ___________________________________________
Seasonal Business? Yes No
3.
If Yes, indicate months business is open:
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
C. If using a credit card terminal connected to a data phone line, please complete the following:
1.
Indicate number of terminals ordered: __________
2.
If using an existing terminal, indicate manufacturer’s name and model: ___________________________
D. If using Internet, Software and/or Wireless, please complete the following:
1.
If your department is redirecting the transmission of credit card data to a third party PCI service provider (i.e.
CyberSource):
a. Internet Service Provider (ISP) Name: ___________________________________________
b. Service Provider’s product name & version #: _____________________________________
c. Department’s website address: ________________________________________________
2.
If your department is using software in processing credit cards: a. Software Name & version #: ________________
b. ISP Name: _____________________ c. Department’s website address: _____________________________
3.
If your department is using a wireless terminal: a. Cellular Company Name: ______________________________
I have read LSU’s Credit Card Merchant Policy (FASOP: AS-22) and agree to the responsibilities, policies, and procedures
established therein. I understand it is my responsibility to supervise the activity of credit card handlers and report any breach
of credit card information and to immediately remedy such (PCI) policies to my staff and perform an annual self-assessment.
Further, if processing Internet transactions, I agree to perform or supervise the required annual assessment and system scan,
if applicable.
_______________________________
______________________________
__________________
Supervisor’s Signature
Print Name
Date
_______________________________
______________________________
__________________
Department Head’s Signature
Print Name
Date
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
FOR ACCOUNTING SERVICES USE ONLY
Processed by __________________________________________
Date ___________________
Rev 06/16
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Parent category: Legal