You must have JavaScript enabled to use this 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: - Select -Clover FlexClover Mini Quantity: Preferred Auto-Settlement Time: - Select -12 AM1 AM2 AM3 AM4 AM5 AM6 AM7 AM8 AM9 AM10 AM11 AM12 PM1 PM2 PM3 PM4 PM5 PM6 PM7 PM8 PM9 PM10 PM11 PM For Online Payment Options: Are you interested in the authorize.net Invoicing option? Yes No Visit the authorize.net Invoicing website for more information. Below will need to be approved by Purchasing and UNLV's PCI Vendor to ensure PCI Compliance. Are you interested in a different 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 Upload requirementsOne file only.2 MB limit. Provide specifics regarding the software application (product name, version number, etc.) Contact 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 Submit Leave this field blank