EMVCo Level 3 Test Tool Supplier Registration Form

EMVCo L3 Test Tool Supplier Request for Registration (new or change request) Date: ___________ Ref: Level 3 Test Tool Supplier – Request for Registration We respectfully request registration of ______________________________ with EMVCo for the purposes of submitting our EMV Level 3 compliant test tool for formal EMVCo qualification. For all correspondence between EMVCo and this company, please utilize the information provided below. We confirm that any subsequent changes to the information provided in this form will be reported to EMVCo in writing in a timely manner. Sincerely, Requestor’s Name: Requestor’s Title: Requestor’s Signature: Copyright ©2021 EMVCo, LLC. All rights reserved

of 4 EMVCo L3 Test Tool Supplier Request for Registration (new or change request) Instructions to Submitters In order to begin the registration process, please complete and submit this form to the EMVCo Level 3 Secretariat: Email: l3_secretariat@emvco.com On receiving the completed form, the EMVCo Level 3 Secretariat will provide the details of the next steps involved in completing the registration process. Company Information: Company Legal Name: State/Country of Incorporation: Full Address of Registered Office: Type of Registration: If Updated Registration, please provide your previous Registration #: Please explain how your company meets the Level 3 Test Tool supplier eligibility requirements:  New Registration  Updated Registration  Current Supplier of L1 Test Tool  Current Supplier of L3 Test Tool  Current Supplier of L3 Test Tool (either qualified or not qualified by EMVCo)  Other – please explain below: __________________________________ Officer of the Company who will sign all agreements with EMVCo: Title: First Name: Last Name: Mailing Address (if different from Registered Address): Telephone Number: Email Address: Copyright ©2021 EMVCo, LLC. All rights reserved

of 4 Contact for Legal Notices: Title: First Name: Last Name: Mailing Address (if different from Registered Address): Telephone Number: Email Address: EMVCo L3 Test Tool Supplier Request for Registration (new or change request) Primary Contact for all communication regarding L3 Qualification: Title: First Name: Last Name: Mailing Address (if different from Registered Address): Telephone Number: Email Address: Secondary Contact for all communication regarding L3 Qualification: Title: First Name: Last Name: Mailing Address (if different from Registered Address): Telephone Number: Email Address: Copyright ©2021 EMVCo, LLC. All rights reserved

of 4 EMVCo L3 Test Tool Supplier Request for Registration (new or change request) Digital format LoQ downloadable on website  Yes, I agree for EMVCo to publish all my EMVCo Letters of Qualification in electronic format online on the EMVCo website http://www.emvco.com  No, I do not agree for EMVCo to publish all my EMVCo Letters of Qualification in electronic format online on the EMVCo website http://www.emvco.com Copyright ©2021 EMVCo, LLC. All rights reserved

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