UNLV New Merchant Account Request Form

Contact Information

First Name:

Last Name:

Department Name:

Title:

Mail Code:

Email Address:

Phone Number:

Department Website Address:

IT Contact (if different from above):

Title:

Email Address:

Business Phone Number:

Workday Account Information

Workday Program:

Workday Program Manager and Unit Manager will need to approve this request

Ledger:

Revenue Category:

Payment Process Details

Estimated Go-Live Date:

Anticipated Annual Sale Volume:

Average Ticket Price:

$

Type of Products Sold

Maximum Ticket Price:

$

Business Type:

What does the business do and what do they sell?

Purpose of Merchant Account (in detail):

Provide Payment Process (from start to finish):

Additional Information or Questions:

For Physical Terminals:

Are you interested in using a physical terminal?

Yes

No

Wells Fargo Equipment Type:

Quantity:

Preferred Auto-Settlement Time:

For Online Payment Options:

This option will need to be approved by Purchasing as well as UNLV's PCI Vendor to ensure PCI Compliance.

Are you interested in an online payment option?

Yes

No

Website address: (authorize.net will act as the interface)

Gateway Provider Name:

Email for Set-Up:

Are you using third party software?

Yes

No

If yes, please request a PCI Attestation of Compliance (AoC) from the company.

Upload PCI Attestation of Compliance (AoC)

Upload requirements

Provide specifics regarding the software application (product name, version number, etc.)

Please fill out, sign and attach page 7 of the UNLV Payment Card Merchant Policy labeled APPENDIX A: Responsibilities of Payment Card Handlers and Processors. The Workday program manager and unit manager of the account information listed above will need to fill out and sign page 7 as well as all employees involved in the department’s handling of cardholder data.

Upload signed UNLV Payment Card Merchant Policy

Upload requirements

Once submitted, your request will be forwarded to the UNLV Controller’s Office for approval. You will receive an email confirmation that your request has been received. Once approved, American Express and Wells Fargo Bank will be notified to start the setup process for your merchant account. Once the merchant account is established, you will receive an email from Wells Fargo Bank. All revenue and fee activity will be posted to Workday into the account information provided above.

If you have any questions or need additional information, please contact:

Kahaunani Hernandez
702-895-5825
pci@unlv.edu

Controller's Office Office of the Controller

Controller's Office

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