Credit Card Terminal Reservation Form
This form must be completed in it's entirety and submitted to the Falcon Exchange, 2nd Floor ECC, with
wet ink signature(s), no later than 5 business days prior to the rental request period. Questions can be
addressed to ext. 7245 or [email protected].
Campus Event
Sponsoring Organization
Student Activity Board (SAB)
Other - Please Specify
Description Event
Location of Event
Location of Ethernet Port
Port Number
Date and Time of Event
Date
Date
Beginning Time
Beginning Time
Ending Time
Ending Time
8 Digit Organization and Account Number
Contact Details & Signature
By signing this form I acknowledge that I have read the Set Up Instructions and the Credit Card Policy &
Procedures. Failure to follow the Set Up Instructions policy and procedures may result in loss of future Credit
Card Terminal privileges. It is understood that damaged or lost equipment will be charged to the individual
and/or the Sponsoring Organization.
Faculty/Staff Sponsor
Faculty/Staff Phone
Faculty/Staff Signature
Faculty/Staff E-mail
Student Name
Student Phone
Student Signature
Student E-mail
For Office Use Only:
Date Submitted: _____ Credit Card Terminal # _____ Transmitted to Accounting: _____
This form last updated by Elliott Sternbergh on March 31, 2016
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