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Once you are ready to participate in the NYUCard Services Campus Cash program and want to purchase the necessary equipment, please complete this form and fax it to our office. Please note that at installation your establishments Tax ID documentation must be present.

If you prefer to fill your form out offline, please click here for a PDF version.

Note: All fields are required.

Merchant Information
Business Name:
Address:
City:
State:
Zip:
Bus. Phone: ( ) -
Fax No.: ( ) -
Verifone Information:
Tranz330- Printer250 Combo ($138) (+ Shipping Costs) How Many:
Tranz380x2- Printer250 Combo ($219) (+ Shipping Costs) How Many:
Tranz330- PrintPack350 Combo ($169) (+ Shipping Costs) How Many:
Tranz380x2- PrintPack350 Combo ($239) (+ Shipping Costs) How Many:
Payment Information
Name on Credit Card:
Credit Card: Visa MasterCard
Discover American Express
Credit Card Number:
Expiration Date:
Billing Address:
Billing City:
Billing State:
Billing Zip:
Cardholder Signature:

By submitting this form, you verify that all information is correct and that you are the person authorized to sign the contract.

Any incorrect information will delay installation by at least a week.
For NYUCard Services Use Only:   Date Sent:           Initials:           Total Sales: