ESD Evaluation Implementation Conformance Statement

Export Form Data Import Form Data ESD Evaluation Implementation Conformance Statement Version 2.3 ICS Reference Number and Validity Period (for EMVCo administrative use only) ICS Reference Number: Valid from: Valid to: Notice: This ICS form shall be completed for products submitted to receive EMVCo ESD Evaluation. The form shall be completed in its entirety. Part I - Administrative Product Provider Identification M Company Legal Name: (As listed on the Letter of Registration) M EMVCo Registration Number: Laboratory Identification M Company Legal Name: M EMVCo Registration Number: ICS Submission Type M Select submission type <ct> C For any submission except Initial, please provide the EMVCo letter of approval reference number of the previously approved product (if already granted) M Is this ICS a replacement of a previously accepted ICS? Yes No C If Yes. Please provide the reference number of the previously accepted ICS C If Yes, please provide the reason for replacing the ICS C If Yes, Please provide details of ICS replacement

PART II – EMV Terminal & IFM Identification The completion of this section is mandatory and shall identify the Terminal in its entirety Device/terminal "Marketing name" evaluated. Device/Terminal Name Device/Terminal version IFM Identification Name IFM Identification Version Power Supply Management Identification (plugged/battery, etc) Screen Identification Network Connection Identification (Wired/Mobile, etc) Application Kernel Name and Version: EMV Kernel Operating System or Platform: Operating System or Platform Version: M Is the IFM already approved? If yes what is IFM (Level 1) Approval Reference (note: LoE can only be issued with a valid L1 LoA) O Is the Level 2 Application Kernel already approved? If yes what is level 2 Approval Reference

PART III – Terminal Option and Grounding description The completion of this section is mandatory M Does the device/Terminal contain a Magnetic Stripe Reader? M Describe the behaviour of the device/terminal when a probe without a mag-stripe or chip is presented (according to section 5 of ESD Test Plan) M Describe any specific grounding requirements that need to be made by the lab whilst the device/terminal is tested. Note: the earth pin of the mains power socket will be grounded. Examples include:

• Grounding via a network cable.
• Grounding via a cash register interface.
• Grounding of the case of an IFM to represent normal installation in a larger acceptance device. M Indicate if more than one grounding configuration should be tested. M Confirm that the above descriptions represent the grounding expected for a typical installation(s) of the device/terminal. C In all cases of specific grounding requirements, the vendor shall supply an appropriate connector, cable, or earthing wire. Please describe how this shall be used by the lab. Part IV - Digital Signatures Product Provider I hereby declare that the above referenced product currently is and will remain in compliance with the above referenced EMV specification for all mandatory and supported optional requirements. Comments Signature Laboratory I hereby declare that this ICS document has been reviewed, and that all product information is consistent throughout the ICS. Comments Signature EMVCo Approval Secretariat Signature