Instructions:
Please fill out the fields below.
Merchant Organization Information
* Required Fields
*
Company Name:
DBA(s):
*
Contact Name:
Title:
*
Telephone:
*
E-Mail:
*
Business Address:
*
City:
*
State/Province:
*
Country:
*
ZIP:
Store Address:
*
Address:
*
City:
*
State/Province:
*
Country:
*
ZIP:
Relationships
Does your company have a relationship with one or more third-party service providers (for example, gateways, web-hosting companies, airline booking agents, loyalty program agents, etc)?
*
Yes
No
Does your company have a relationship with one or more acquirer?
*
Yes
No
Transaction Processing
*
Payment Equipment in use: If you have multiple terminals, you can select up 5 different terminal types.
Confirmation of Compliant Status
Merchant Confirms
*
I have read the
PCI DSS
and I recognize that I must maintain full PCI DSS compliance at all times.
*
No evidence of magnetic stripe (i.e., track) data, CAV2, CVC2, CID, or CVV2 data, or PIN data storage after transaction authorization was found on any systems reviewed during this assessment.