Create New Merchant Site Request Form

Date:
After completing this form, please mail it to Warriner Hall 205 or fax it to 989-774-1069.
Site Contact Information
First Name Last Name
Title/Position Department
CMU Global ID Work Phone Fax

Merchant Site Information
Requested Site Name (24 Character Max)
 

Site Address
Correspondence should go to the attention of:
Address
City State Zip

Select the type of credit cards your site would like to
accept:
Select the type of payments your site would like to accept: 		 
Visa/Master Card: 
Yes  No
American Express:
Yes  No
Discover Card:
Yes  No

Online: 
Yes  No
Manual:
Yes  No
Projected Sales for new Merchant Site
Average Sale
Amount (each purchase) $:		 Estimated Annual Sales: Product/Services Sold :
 
Charge Merchant Fees to:
Cost Center GL Account
751100

I agree that by submitting this form I am requesting to open a new CMU Merchant Site. I agree to follow all
policies and procedures set by Payroll/Travel Services, the credit card companies and CMU's contracted service providers.

Signature ___________________________________ Date_____________________