Request for Renewal – CCD/CPA Product

Common Core Definitions / Common Payment Application Approved Card Renewal Request Form Version FORMTEXT 1.0 Renewal Request Number and Validity Period (for EMVCo administrative use only) Renewal Request Number: FORMTEXT           Val id from: FORMTEXT           Valid to: FORMTEXT           Notice: This form is for requesting an approval renewal of an EMVCo Common Core Definitions / Common Payment Application previously approved by EMVCo. Submission of this form does not constitute approval for the renewal; it merely provides information upon which EMVCo can determine whether additional testing will be required and that the Product Provider wishes to renew the approval as described in this form. After this form has been completed and reviewed by EMVCo, the Product Provider will be advised if the request is acceptable to EMVCo and what additional information or steps will need to be taken to complete the process. A - Administrative Product Provider Identification A.1.1 – Company Legal Name: (As listed on the Letter of Registration) FORMTEXT           A.1.2 – EMVCo Registration Number: FORMTEXT           Approved Card A.2. 1 – Please provide the previously approved card ICS Reference Number FORMTEXT           A.2.2 – Original Approval Date FORMTEXT           A.2.3 – Current Approval Expiration Date FORMTEXT           Laboratories A.3.1 – Laboratory to perform the Security Evaluation FORMTEXT           A.3.2 – Laboratory to perform the Functional Testing (if required) FORMTEXT           This Approval Renewal Request Form must be signed by a representative who is authorized to act on behalf of and legally bind the Product Provider. The undersigned parties have entered into an EMVCo Card Type Approval Contract ("Contract"), and desire to execute this form to extend the approval for a previously approved product. This form is subject to all conditions as specified in the Contract. Product Provider’s Officer Name: FORMTEXT           Title: FORMTEXT           FORMCHECKBOX I hereby declare the referenced card product meets current: EMVCo Specifications (including bulletins), EMVCo Testing Requirements (test case versions, card image requirements), EMVCo Security Requirements, and EMVCo Approved Chips Signature: FORMTEXT           Date: FORMTEXT