Temporary Merchant Site Request Form

Date:
After completing this form, please mail it to Warriner Hall 205 or fax it to 989-774-1069.

Name

Title/Position

Department

Email Address @cmich.edu

Phone Number Fax Number


What are you accepting payment for?

When do you want to start accepting credit card payments?

How long do you want to accept credit card payments?

How many people will need access to process credit card transactions? Please list their names.

Name Global ID Date to Cancel Access

Charge Fees to Cost Center GL 7511

Estimated Monthly Sales

Average Ticket Size

I agree that by submitting this form, I am requesting to process credit cards using a CMU Merchant Site. I understand that credit card information is sensitive data and should be stored in a secure environment. 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 ________________

Please fax this form to 989-774-1069 Attn. Sara Yonkey.