Site Registration Questionnaire: Product Providers

Instructions: P lease complete all sections. Each development or production site must be submitted on separate forms. F or additional instructions refer to the attached Registration Questionnaire Instructions. Return completed Site Registration Questionnaire, as a PDF, by email to the EMVCo Security Evaluation Secretariat. Email: securityevaluation@emvco.com 1. General Information: Company Name: FORMTEXT           Security Lab oratory Name: FORMTEXT           Publishing Approval: FORMCHECKBOX Yes please include in the Approved Sites list. FORMCHECKBOX No please exclude from the Approved Sites list. 2. Site I dentification: EMVCo approves product development and production sites, up to the stage where the product Flash memory is programmed if applicable. Site name: FORMTEXT           Site type: FORMCHECKBOX Development FORMCHECKBOX Production Site address: FORMTEXT           FORMTEXT           3. Contact Information: Contact Name: FORMTEXT           Contact email: FORMTEXT           Date Completed: FORMTEXT           4. Authorized b y: Name: FORMTEXT           E mail: FORMTEXT           Date Authorized: FORMTEXT           Instruction s for Site Registration Questionnaire 1. Company Name: Enter the name of the company that has registered with EMVCo as a product provider. Security Lab oratory Name: Enter the name of the Security Evaluation Laboratory you plan to use for the security audit of your development or production site. Publishing Approval: Indicate if you want your development or production site listed on the Approved Site list that is posted to the EMVCo "public" website: or if you would like to have your site approval kept "private" and not included in the approved sites list. 2. Site identification: Indicate the name of the site being audited for approval. Specify whether the site is a development or production location for EMVCo products, and specify the full site address (including street and number, zip code, city, country). 3. Contact Information: Enter the name and email of the perso n EMVCo should contact if there are any questions related to the information provided on the questionnaire. Please enter the date the questionnaire was completed. 4. Authorized By: Enter the name of the person who authorize d the audit of the site detailed in the questionnaire.