Section 1: Assessment Information Instructions for Submission This document must be completed as a declaration of the results of the merchant’s self-assessment with the Payment Card Industry Data Security Standard Requirements and Security Assessment Procedures (PCI DSS). Complete all sections: The merchant is responsible for ensuring that each section is completed by the relevant parties, as applicable. Contact acquirer (merchant bank) or the payment brands to determine reporting and submission procedures. Part 1. Merchant and Qualified Security Assessor Information Part 1a. Merchant Organization Information Company Name: DBA (doing business as): Contact Name: Title: Telephone: E-mail: Business Address: City: State/Province: Country: Zip: URL: Part 1b. Qualified Security Assessor Company Information (if applicable) Company Name: Lead QSA Contact Name: Title: Telephone: E-mail: Business Address: City: State/Province: Country: Zip: URL: Part 2. Executive Summary Part 2a. Type of Merchant Business (check all that apply) Retailer Telecommunication Grocery and Supermarkets Petroleum E-Commerce Mail order (MOTO) Others (please specify): What of payment channels does your business payment channels are covered by this SAQ? serve? Mail order (MOTO) Mail order/telephone order (MOTO) E-Commerce E-Commerce Card-present (face-to-face) Card-present (face-to-face) Note: If your organization has a payment channel or process that is not covered by this SAQ, consult your acquirer or payment brand about validation for the other channels. Part 2b. Description of Payment Card Business
Section 1: Assessment Information Instructions for Submission This document must be completed as a declaration of the results of the merchant’s self-assessment with the Payment Card Industry Data Security Standard Requirements and Security Assessment Procedures (PCI DSS). Complete all sections: The merchant is responsible for ensuring that each section is completed by the relevant parties, as applicable. Contact acquirer (merchant bank) or the payment brands to determine reporting and submission procedures. Part 1. Merchant and Qualified Security Assessor Information Part 1a. Merchant Organization Information Company Name: DBA (doing business as): Contact Name: Title: Telephone: E-mail: Business Address: City: State/Province: Country: Zip: URL: Part 1b. Qualified Security Assessor Company Information (if applicable) Company Name: Lead QSA Contact Name: Title: Telephone: E-mail: Business Address: City: State/Province: Country: Zip: URL: Part 2. Executive Summary Part 2a. Type of Merchant Business (check all that apply) Retailer Telecommunication Grocery and Supermarkets Petroleum E-Commerce Mail order (MOTO) Others (please specify): What of payment channels does your business serve? Mail order (MOTO) E-Commerce Card-present (face-to-face) payment channels are covered by this SAQ? Mail order/telephone order (MOTO) E-Commerce Card-present (face-to-face) Note: If your organization has a payment channel or process that is not covered by this SAQ, consult your acquirer or payment brand about validation for the other channels. Part 2b. Description of Payment Card Business