Department Name (Merchant Name): _______________________________________________

Department Address: ____________________________________________________________

Contact Name: _________________________________________________________________

Phone Number: _________________________ Email: _________________________________

My Department will be accepting payment cards as payment for the following products and or services:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Will the merchant department be accepting payment for a limited duration and/or

one time event? _____Yes _____No

If yes, please indicate anticipated beginning and ending date:

Beginning date: _________________ Ending date: _________________

The sale of products or services described above will be reviewed for compliance with the Board of Regents policy on Competition with the Private Sector. A copy of this policy may be found at the following Internet site: http://http://www.adp.iastate.edu/vpbf/prod/docs/upm/chap11.htm#11.1.1. Please explain why you believe selling these products or services is not in competition with the Private Sector:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

It is the responsibility of the merchant department to notify the Director of Business Affairs (ph.294-4701) prior to selling any additional products or services not previously approved for sale, so the appropriate competition with the private sector review can occur.

I have read and agree to comply with the E-commerce Policy for University Departments and Affiliates with the following exceptions or special requests:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

If approved, the authority to process Internet payments will automatically expire December 31st of the year authorization is granted . Thereafter, the merchants may annually request renewal of authority to process Internet payments, subject to ECRC review and approval.