HomeMy Public PortalAboutJetPay2011ApplicationAgreementPayment Card lIndustry Data Security Standard Merchant Options
Active PCI DSS compliance is required to obtain a merchant account. By participating in our PCI Compliance
program, you will gain access to full PCI DSS compliance documentation, assistance in completing any necessary
tasks required to become compliant and gain access to a PCI Breach Insurance policy by Royal Group Services Ltd.,
LLC. Your coverage will begin on the first day of the month after signing this agreement. The below contact listed
will be contacted with login information and access directions.
Does the merchant use: Software X Terminal El ? /
If Terminal, what type: tv 1ZE&15T'e � ? `
If Software, Payment Application Name:
If Software, what is the version of the Payment Application in use:
Is your organization currently PCI DSS Compliant? Yes ❑ No ❑
If Yes, who is your current qualified security assessor?
If Yes, please include the most recent copy of your PCI DSS certification.
PCI Contact Information:
CONTACT NAME CONTACT EMAIL CONTACT TELEPHONE FAX NUMBER
ADDRESS
The PCI Compliance program includes access to and assistance with the Self Assessment Questionnaire including
task management for out-of-compliance items and policy assistance (PCI ToolKit by CSRSI, Inc.), PCI quarterly
scans` and coverage for up to $50,000 per each merchant identification number (MID) for any one incident or in any
year. For merchants with 10 or more insured MIDs, there is an aggregate limit of $500,000 for any one incident or in
any one year.
Merchants who opt out of the PCI Toolkit/Scanning portion are still required to have breach insurance. For pricing,
see your Schedule A. If you do not choose the annual option on the Schedule A, our system will default to monthly
billing. Merchants can opt out of the PCI Compliance program but will be required to provide full compliance
certification through their current provider as well as a copy of the merchant's active PCI Breach insurance on an
annual basis. Information regarding PCI DSS is available at. https : / /wwvv.pcisecuritystandards -M . Questions
regarding PCI DSS or PCI Breach insurance can be emailed to _ complianceCevietpay.com .
* PCI scanning included in package pricing is based on one IP per merchant account. Additional fees may apply if there is additional IN
requiring the PCI scan.
INITIAL
Rev 070110_33
EXHIBIT 1
IMPORTANT INFORMATION ABOUT PROCEDURES
FOR OPENING A NEW ACCOUNT
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to
obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an
account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask
to see your driver's license or other identifying documents.
ATTACH VOWED CHECK HERE
A voided check from your checking account must be included in this application
(Jo not use a deposit ticket or temporary check)
ATTACH COPY OF PRINCIPAL'S DRIVERS LICENSE HE C
(or on a separate page for all principals listed on the first page of this agreement)
//
ATTACH COPY SECuNDARY PRIMO AL IDENTIFICATION HERE
(or on a separate page for all rc incipals listed on the first page of this agreement)
(Any one of the following) Current lito In. rance Card or Registration
Current Uti a ill
Employer ! • C: • with Photo
Most !: -cent Com.• 1 -te Tax Return
r. • - . Recent Real Est. Bill
Rev 0701 10_33