Credit Card Merchant Request Form

Request approval to become a state merchant that accepts credit cards as a form of payment.

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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Lance Mahalic
Financial Management
418 Crofts Hall
North Campus

Need Help Completing the Form?

Lance Mahalic.

Lance Mahalic

IFR, Revenue Accounting and Treasury Management

Financial Management

Phone: 716-645-2626


Tricia Canty.

Tricia Canty

Policy, Compliance and Internal Controls

Phone: 716-645-2639


Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: 9/2019

Owner: Financial Management