UNIVERSITY OF CALIFORNIA LOS ANGELES BUSINESS AND FINANCE SERVICES	PAYMENT SOLUTIONS & COMPLIANCE 1125 Murphy Hall Los Angeles, CA 90095-7089 Phone: (310) 794-5333 | Fax: (310)206-0642

NEW MERCHANT - SET UP QUESTIONNAIRE

Contact Payment Solutions and Compliance to assess your needs and requirements.

FILL, SIGN, AND SEND the completed questionnaire via MyUcla messaging center.

Please submit a separate form for each location/site. (PLEASE ALSO CC THE FUND MANAGER OF THE FUND INDICATED IN SECTION V. OF THIS FORM).

I. DEPARTMENT GENERAL INFORMATION

Name of department:	Click or tap here to enter text.	Doing Business As (DBA): UCLA	Click or tap here to enter text.
Please note that this name will appear in your customers’ receipts and their credit card statements. (Limit to 10 characters).
Business Mailing Address: City, State ZIP Code	Click or tap here to enter text.	Business Phone Number:	Click or tap here to enter text.
Business Purpose: (Brief description of the business activity, including goods/services you are offering:)	Click or tap here to enter text.

Who will your customers be? (Please check all that apply).

Students	Staff	Faculty
Alumni	Medical Patients	External customer/entities

What kind of payments will you be taking? (Please check all that apply).

In Person Only:	Online Only:
Cash	Credit Card
Check	eCheck (ACH)
Credit Card

Please choose the deposit location for your department: Choose a Deposit Location.

II. DEPARTMENT MAIN CONTACT INFORMATION

This “person” is responsible for all credit/debit card processes and will be the main contact for PSC.

Name (first, last):	Click or tap here to enter text.	University ID:	Click or tap here to enter text.
Position Title:	Click or tap here to enter text.	Mail Code:	Click or tap here to enter text.
Department Code:	Click or tap here to enter text.	Department Name:	Click or tap here to enter text.
(as it appears on the UCLA directory). Non-UCLA department, use dept. code 9330.
Email:	Click or tap here to enter text.	Phone:	Click or tap here to enter text.
Fax:	Click or tap here to enter text.	Other:	Click or tap here to enter text.

III. MERCHANT TYPE

In order to determine the merchant type, you are requesting, please read the following and select the appropriate box.

☐ E-commerce merchant

You are requesting an E-Commerce merchant if: your customer (the cardholder) will be making a payment, deposit,

or donation online.

Regular order (2 or 3 weeks)	RUSH order (within 1-2 weeks - $75 fee for all RUSH requests for checkout sites only)

☐ Credit Card Terminal merchant

You are requesting a stand-alone terminal if: the merchant (department) will be processing a payment, deposit, or donation in person. The terminal is not integrated with a cash register/software /hardware and the credit card information cannot be captured in the cash register/software/hardware. Note: Terminal requires an analog phone line and must be located on the counter area for customers to access.

Regular order (2 or 3 weeks)	RUSH order (within 1-2 weeks - $75 fee for all RUSH requests for checkout sites only)
Please indicate the number of terminals you require:	Choose a number.
Please indicate if you will be accepting debit payments:	Yes No
Terminal – Rental FD-130 Duo Monthly Fee $35.90 – Recommended FD-130 Monthly Fee $35.90 – Recommended FD-35 Pin Pad Fee $12.50 - Recommended FD-410 Monthly Fee $92.00 – Recommended	Terminal – Purchase FD-130 Duo One-time Purchase $600.00 FD-130 One-time Purchase $600.00 FD-35 Pin Pad One-time Purchase $127.27 FD-410 One-time Purchase $799.25 (Owner is totally responsible for terminal malfunction or breakdown
Terminal Model: Choose a model (If other, please contact PSC whom will provide more information).

IV. DEPARTMENT INFORMATION

Estimated average ticket price per transaction:	Choose a price.

Estimated total sales (if no determinable end date, indicate per year):	Choose a total amount.

FAU (Full Accounting Unit) for income account. Chargebacks, if any, will be applied to this account.

*Account number must begin with a 1 or 2.

LOC (1)	ACCOUNT* (6)	CC (2)	FUND (5)	SUB (2)	OBJECT (4)	SOURCE (6)	DESCRIPTION (20)	REFERENCE (10)

Fund Financial Manager of this FAU income account:	Click or tap here to enter text.

FAU (Full Accounting Unit) for credit card fee recharges.

*Account number must begin with a 4 or above.

LOC (1)	ACCOUNT* (6)	CC (2)	FUND (5)	SUB (2)	OBJECT (4)	SOURCE (6)	DESCRIPTION (20)	REFERENCE (10)
Fund Financial Manager of this FAU income account:	Click or tap here to enter text.

Bank fees: Varies depending on the volume of monthly transactions.

Recharge fees: 0.1385% of the monthly total amount.

V. ITEM CODE INFORMATION

What is an Item Codes?

An item code is an alpha-numeric code that correlates to a Full Accounting Unit (FAU). A separate item code will need to be created for each FAU pertaining to in-person or online payments.

How to create an Item Code?

To create an item code, please complete the template below. Note: the first five digits of the item are fixed to include the number "4" followed by the four-digit department code. The remaining seven digits can be used to identify the name of the item code. The seven digits can be alpha, numeric or alpha-numeric. For Example: FAU 4- 264210-64210 University Elementary School Parking for department 0080 item code could be 40080UNELSCP. Please use this example as guide to build your department item code(s).

Will you be utilizing the explanation field to track additional information in CASHNet?	Yes No

This field allows the department to add additional notes to an in-person payment within CASHNet. This information is not available in the Campus Data Warehouse and will only be viewable within CASHNet.

Please fill out the item code form below. Each row corresponds to one item code. If a recharge FAU (expense account) is not specified for each item code all credit card fees will be recharged to the FAU specified on page 3. The maximum character count is provided in the parentheses below each field.

*Account must be an income account and begin with a 1 or 2

DEPT CODE (4)	ITEM CODE NAME (7 Characters alpha or numeric or alphanumeric)	ITEM CODE DESCRIPTION (30)	LOC (1)	ACCOUNT* (6)	COST CENTER (2)	FUND (5)	PROJECT (6)	SUB (2)	OBJECT (4)	SOURCE (6)	REFERENCE (10)	LEDGER DESCRIPTION (20)	RECHARGE FAU (EXPENSE ACCOUNT)
0080	UNELSCP	University Elementary School Parking	4	264210	64210	4-65432-12345
4
4
4
4
4
4
4
4
4
4
4

VI. UCLA CASHIERING POLICIES AND FORMS

A. Policies for Cash and Check

Please confirm you have read the following policies and are operating in accordance with the requirements to process cash and check payments.

Policy Description	Policy Name	Policy Acknowledgement
Cashiering Responsibilities and Guidelines	BUS-49	Please confirm that you have read BUS-49. Yes No
Cash Handling Safety and Security	UCLA Policy 361	Please confirm that you have read UCLA Policy 361. Yes No
Safe Requirements	UCLA Safe Requirements	Please confirm that you have read the UCLA Safe Requirements. Yes No

B. Additional forms needed for a merchant to accept cash and/or check payments

Please confirm all additional forms and have completed and submitted to MyUcla message center. If they have not yet been completed, please do so at this time to ensure all supplies are available to begin accepting payments at this location.

Additional Forms Needed	Required for Cash	Required for Checks	Required for Cash and Checks	Has this been sent to MyUcla message center?	If yes, what is the 8 digit case number assigned (A0001234)?
Cash Handling Documentation Requirements	x	x	x	Yes No
Dunbar New Location Form	x	x	x	Yes No
Deposit Slips	x	x	x	Yes No
Endorsement Stamps	x	x	Yes No
Bank of America Deposit Bags	x	x	x	N/A	N/A
CASHNet Operator Setup Form	x	x	x	Yes No
Check Scanner Request Form	X	Yes No

VII. SEPARATION OF DUTIES ACKNOWLEDGEMENT

UNIVERSITY OF CALIFORNIA, LOS ANGELES UCLA

______________________________________________________________________________________________________________________ ______________________________________

BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ

______________________________________________________________________________________________________________________ ______________________________________

UCLA Payment Solutions & Compliance 1125 Murphy Hall Los Angeles, CA 90095 Phone: 310.794.5333

Department Name:	Click or tap here to enter text.
Location #:	Click or tap here to enter text.

I, Click or tap here to enter text. , acknowledge that department Click or tap here to enter text. is working within the guidelines outlined in BUS49 related to separation of duties. This acknowledgement is a request for processing payments. Outlined below is the separation of duties between billing/invoicing and posting payments, and not one person is every solely responsible for both tasks.

Individuals Responsible for posting payments:	Individuals responsible for billing/invoicing:
Click or tap here to enter text.	Click or tap here to enter text.

This acknowledgement must be certified by the departments head on an annual basis confirming the separation of duties and the individuals responsible for each task. If you have any questions or need further guidance please reach out to Payment Solutions & Compliance, 310.794.5333.

Department Head Name (printed): Click or tap here to enter text.	Date: Click or tap to enter a date.

Signature:

VIII. E-COMMERCE MERCHANTS ONLY

A. Please choose your e-commerce set up.

Service guarantee: Please allow 7-14 business days to set up test site, perform appropriate testing, and move site to production.

☐ Checkout –The Checkout method gives departments websites the ability to process credit cards and electronic

checks (ACH). The customer begins on the department’s website so departments have complete control over the

user interface looks and feel. Once the customer selects the item or items to be purchased the site will transfer the

customer to a CASHNet website

☐ Storefront – The Storefront method gives departments with limited resources the ability to accept credit cards and

electronic checks (ACH). The customer begins on a CASHNet website where the items for purchase are displayed.

Customers make and pay for their selections entirely on the CASHNet website.

Please visit the below example sites which shows the various features within CASHNet Storefront.

SAMPLE STORE

SAMPLE CONFERENCE

SAMPLE REGISTRATION SITE

B. E-commerce Event Information

Event/Conference Name:	Click or tap here to enter text.
Is this a reoccurring event for your department?	Yes No
Has this site been used previously?	Yes No
If you answered yes, please specify the previous site name or merchant code:	Click or tap here to enter text.	YEAR-MM-DD (if applicable):	Click or tap to enter a date.

Would you like to use Smart Pay? Smart Pay allows the merchant to pass on the credit card fees to the customer. This feature can only be used to pay for education and registration fees. Must be approved by Director and Manager within PSC.	Yes No
Expected end date to disable E-market site:	Click or tap to enter a date.

Would you like to provide a banner or have PSC create a generic banner for your department eMarket site?
Yes, I would like to provide a banner. No, I would like PSC to create a generic banner for my department If yes, please attach a file titled banner with this form. (Add banner requirements)

Are you offering a discount code? Only one discount is allowed per store at any given time.	Yes No
If you answered yes, please complete the following information.
Deadline for discount:	Click or tap to enter a date.	Discount details:	Click or tap here to enter text.

C. Storefront Information

This additional information only needs to be completed if you selected storefront as your e-commerce setup. Please refer to the sample storefront sites to better understand the setup options. They have been provided to give you visual examples of different setup options available to choose from.

If you are selling merchandise, are you charging CA sales tax? If no, why? If yes, how is sales tax being recorded?
Yes	No
Explain:	Explain:
Click or tap here to enter text.	Click or tap here to enter text.
Would you be setting up sub categories?	Yes	No
If you answered yes, list the different sub categories below:
1.	Click or tap here to enter text.
2.	Click or tap here to enter text.
3.	Click or tap here to enter text.
4.	Click or tap here to enter text.
Do you have images for your merchandise:	Yes No
If you answered yes, please attach each image to this email with the image titled with its corresponding item code name.
Required References for store wide purchases:	First, Last Name	Phone Number	Department	Click or tap here to enter text.
Email	Work Number	Fax	Click or tap here to enter text.
Address	Cell Phone Number	Company/University/ Affiliation/etc.	Click or tap here to enter text.
Dietary Restrictions	Click or tap here to enter text.	Click or tap here to enter text.
Any additional information needed? Please specify.	Click or tap here to enter text.
Optional References for store wide purchases:	First, Last Name	Phone Number	Department	Click or tap here to enter text.
Email	Work Number	Fax	Click or tap here to enter text.
Address	Cell Phone Number	Company/University/ Affiliation/etc.	Click or tap here to enter text.
Dietary Restrictions	Click or tap here to enter text.	Click or tap here to enter text.
Any additional information needed? Please specify.	Click or tap here to enter text.

Please fill out the form below for storefront specific item codes.

*Match will the corresponding subcategory letter provided on page 6.

Item Code Name (Match with page 4)	Price	Featured?	Inventory	Sub Category?*	Add On (List the Item Code Name you would like this item code added on to?)	Image	Long Description (150 character count)
43580STORE-1	27.00	YES	144	1	43580STORE-3	YES	100% cotton with screen-print and clear rhinestones.
Yes /No	Yes /No
Yes /No	Yes /No
Yes /No	Yes /No
Yes /No	Yes /No
Yes /No	Yes /No
Yes /No	Yes /No
Yes /No	Yes /No

IX. INDIVIDUALS INVOLVED IN MERCHANT PROCESSES (CREDIT/DEBIT CARD PROCESS)

Indicate the names of all individuals (Department main contact, faculty, staff, students, casuals, volunteers, web designers) who will be involved in the merchant process (include titles and how they will be involved).

University ID:	Click or tap here to enter text.	Name (first, last):	Click or tap here to enter text.
Email Address:	Click or tap here to enter text.	Title:	Click or tap here to enter text.
Role in the merchant process:	Choose a role.	Permission Code:	Choose a permission code.
Has the individual read the PCI Manual and accepted policies & procedures?	Yes No
Will the individual have access to security codes: CVV2, CVC2 & CID along with the credit card number?	Yes No
Will the individual have access to the incident response plan, risk assessment, and information security policy?	Yes No
Should the individual be provided access to CASHNet (reporting tool)?	Yes No
Should the individual be provided access to credit card enabled web applications?	Yes No

Click the + sign at the above right corner table for additional entries.

Notes:

(1) Any time a change in staff occurs, please send us an email via MyUcla message center.

(2) Examples are: taking credit card information over the phone, mailed envelopes, transmit the payment form by internal mail, access to cabinet where the payment form will be stored, etc.

X. PCI-DSS Standards

Will you:
Allow customers to use your department desktop/labtop/kiosk/mobile or any other device to make a payment, or deposit on your website?	Yes No
Collect credit card information over the phone from your customers in order to process the payment, or deposit through your website on your customer’s behalf?	Yes No
If you answered yes to either of the two questions above, your desktop(s) is subject to PCI-DSS standards and the Campus Credit Card Coordinator will be in communication with you. https://www.finance.ucla.edu/business-finance-services/payment-solutions-and-compliance/pci-dss-security-awareness-education-sae-training https://www.pcisecuritystandards.org/security_standards/index.php
Point of Sale (POS) merchant You are a Point of Sale (POS) merchant if your customer (the cardholder) must insert or swipe the card in the PIN Pad. In order to make a payment, deposit, or donation. The terminal (PIN Pad) is integrated with a cash register/software/Hardware/ Model/Vendor Information.
Please indicate the number of POS being implemented:	Choose an item.
Please describe the database/system/software/hardware that you will be using:	Click or tap here to enter text.
Please provide the name, job title and approval date of your database/system/software.	Click or tap here to enter text.

XI. CUSTOMER ORDER FORMS & FAXING

Disclaimer - According to BUS 49 - Policy VIIII. Prohibits payment with credit card/debit card via fax transmission - The University should not accept payment instructions via fax transmission. This practice is prohibited as a violation of the intent of section 4(a) of the Uniform Commercial Code.

Will you be creating course registration or customer order forms with credit card information?	Yes No

If yes, please confirm that these forms will clearly indicate that they can only be faxed to the merchant’s fax number or delivered in person (if applicable).

Disclaimer example: “For security reasons, please do not send your credit card information electronically (email, instant message, scanned document, etc.). To fax this form, please sent it to fax number: (123) 123-4567 or bring it to the following address 1234 Abc Street, Suite 123, Los Angeles, CA 12345.”

Yes, I confirm.	No	N/A

XII. CARDHOLDER DATA & FAXING

Will you be receiving cardholder data on documents via fax:	Yes No
If yes, please select the type of fax machine you will be using:
A dedicated fax machine in a secure controlled environment.
A shared fax machine with an identification functionality (password is required to release document).

XIII. SUPPORTING DOCUMENTATION/PROOF OF SETTLEMENT

A. Will you be retaining any supporting documentation and/or proof of settlement which contains cardholder data?	Yes No
If yes, read and select each statement below to acknowledge that this step will followed:
Redact the primary account number (PAN) last 4 digits of the number may remain visible.
Shred the original document.
Retain only the photocopied document.
If you are considering to photocopy credit card information, it is a permitted process subject for further discussion. Please contact the Campus Credit Card Coordinator for details at bgraciano@finance.ucla.edu
B. How long will you be retaining the supporting documentation?	Click or tap here to enter text.
(You may refer to the UCLA records retention schedule) https://www.finance.ucla.edu/tax-records/records-management/ucla-retention-disposition-schedules-policies
C. Please confirm that you are not printing reports that contain full credit card information.
Yes, I confirm.	No	N/A
If you will be printing reports that contain credit card information, please provide business justification.
D. Please confirm that you are not collecting nor storing the credit card value (CVV).
Yes, I confirm.	No	N/A

XIV. SCANNING

A. If you are scanning any document (e.g. customer order form, supporting documentation, and proof of payment) that contains cardholder data, please confirm that you will redact the PAN except for the last 4 digits before scanning.

Yes, I confirm.	N/A, I do not scan.

B. Also confirm, that once your documents are scanned and saved on your network, you will then shred the original documents using cross-cuts shredder or approved vendor.

Yes, I confirm.	N/A, I do not scan.

If you will be scanning documents that contain full credit card information, please contact the Campus Credit Card Coordinator.

XV. DISPOSAL REQUIREMENTS

A. If documents that contain cardholder data are shredded, please confirm the type of shredder you will be using:

Cross-cuts	Micro-cuts

B. If the shredder stores paper, prior to shredding, please confirm the container is securely locked.

Yes, I confirm.	N/A

C. If documents that contain cardholder data are to be transported in boxes, please confirm that the boxes are sealed prior to being in transit.

Yes, I confirm.	N/A

XVI. SERVICE PROVIDERS

If Service Providers (transportation, shredding, website Developers/companies) are involved in the merchant Process, please provide the name of the company:	Click or tap here to enter text.
Note: PCI will confirm that the service provider is PCI-DSS Compliant.
Provide station of authenticity of compliance for reference.	Click or tap here to enter text.

Please attach a copy of contract if already signed with this form.

SIGN OFF – DEPARTMENT MAIN CONTACT

University ID:	Click or tap here to enter text.	Print Name (first, last):	Click or tap here to enter text.
Signature:	Date:	Click or tap to enter a date.

REQUESTED BY (if different from the Department Main Contact)

Name (first, last):	Click or tap here to enter text.	Department:	Click or tap here to enter text.
Email:	Click or tap here to enter text.	Phone:	Click or tap here to enter text.
University ID:	Click or tap here to enter text.	Print Name (first, last):	Click or tap here to enter text.
Signature:	Date:	Click or tap to enter a date.

ADMINISTRATIVE OFFICE USE ONLY

Department Name:	Click or tap here to enter text.	Department Code:	Click or tap here to enter text.
Contact Name:	Click or tap here to enter text.	Contact Phone:	Click or tap here to enter text.
Merchant Name:	Click or tap here to enter text.	Rush or Regular Order:	Click or tap here to enter text.
Bank Account and Routing#	MCC:	Click or tap here to enter text.	Click or tap here to enter text.	121000358
DESCRIPTION	BAMS	AMEX
CHAIN/CAPS/SET MANAGER	Click or tap here to enter text.	Click or tap here to enter text.
MID	Click or tap here to enter text.	Click or tap here to enter text.
NASHVILLE MID	Click or tap here to enter text.
DID	Click or tap here to enter text.
TIN – Tax ID	Click or tap here to enter text.
TID – Terminal ID	Click or tap here to enter text.
Deposit Slips	Click or tap here to enter text.
Dunbar	Click or tap here to enter text.
Endorsement Stamps	Click or tap here to enter text.

CREDIT CARD TERMINAL

Item Code:	Click or tap here to enter text.	Pay code:	Click or tap here to enter text.
Item Code:	Click or tap here to enter text.	Pay code:	Click or tap here to enter text.
Item Code:	Click or tap here to enter text.	Pay code:	Click or tap here to enter text.
Date sent to BAMS:	Click or tap here to enter text.	Date sent to AMEX:	Click or tap here to enter text.
Tracking#	Click or tap here to enter text.	Carrier:	Choose an item.	Shipped:	Click or tap to enter a date.
Date Received by Stakeholder:	Click or tap here to enter text.	Final Set Up Date:	Click or tap to enter a date.

E-COMMERCE – STORE

Site/Event Name:	Click or tap here to enter text.
Date move site to production:	Click or tap to enter a date.
Test Server IP address:	Click or tap here to enter text.	Production Server IP address:	Click or tap here to enter text.

Default Customer Code	Location	Station	Operator	Merchant
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

NOTES:	Click or tap here to enter text.