Credit Card Terminal Request Form

Contact Information

Name *

NSU ID *

Email: *

Phone Number *

Do you have a 4-Digit PIN? *

Yes No

Name of all individuals using the machine.
Note: Only individuals who have been PCI Compliance trained BEFORE their rental are authorized to use the machine

Name 1 *

Name 2

Name 3

College and Organization Information

Organization Name *

Affiliation *

Event Information

NOTE: One request form is required per event

Event Name*

Event Date *

Rental Period Begins (Pick Up Date): *

Rental Period Begins (Time) *

Rental Period Ends (Date of Return): *

Rental Period Ends (Time) *

Pickup and Dropoff times are only available Monday through Friday, 9:00 a.m. to 5:00 p.m.

Event Location *

Brief Description of Event : *

* Terms of Agreement - By checking this box, I agree with the terms below

The Student Activity Fee Accounts Office agrees to allow you to use a wireless point-of-sale credit card machine for the purpose of collecting monies via in-person credit card sales under the following conditions.

Only individuals who have been PCI Compliance trained BEFORE their rental are authorized to use the machine.
The renter will be required to pick up and return the equipment.
All equipment must be stored in a locked and secure area when not in use.
Renters will be responsible for the replacement cost of the device and the charger if the device/charger is lost, stolen or damaged while in their possession.

Equipment may be collected from and returned to the Student Activity Fee Accounts Office Monday - Friday between the hours of 9:00 a.m. and 5:00 p.m.

Please contact the Student Activity Fee Accounts Office at (954) 262-7290 or studente@nova.edu for any questions regarding the rental process.

Please verify that you have completed all required fields and are not a robot before submitting this form.