Technology Innovation Program

Merchant PCI DSS Validation Waiver Application

(Acquirer Name)

(Visa Business ID)

(Date)

*(Merchant Company Name) [*If multiple, see page 2]

(Merchant Country)

Instructions for Submission

Visa acquirer must complete all applicable sections and submit application to local Visa Payment System Risk team. Note: Incomplete applications or those submitted for merchants not meeting criteria will not be accepted.

Merchant Level:

(check one)

Level 2

Level 1

Visa Client Confirms:

1. Merchant validated PCI DSS compliance. (Prior validation is not a condition for approval.)

YES

NO

2. Merchant confirmed that sensitive authentication data (i.e., full contents of magnetic stripe, CVV2 or PIN data) is not stored on any system subsequent to transaction authorization.

3. Merchant has not been involved in breach of cardholder data.

4. At least 75% of merchant’s transactions originate through one of the following secure acceptance channels:

1. Enabled chip-reading terminals (U.S. merchants must use dual interface terminals)

% of transactions _________

2. PCI-Validated Point-to-Point Encryption Solution

% of transactions _________ Solution Name: _______________________

Chip-enabled terminals must have current, valid EMV approval and pass Visa Acquirer Device Validation Toolkit (ADVT) / Visa payWave Test Tool (VpTT) implementation requirements as applicable.

Point-to-Point Encryption solution must be included on PCI SSC’s list of validated solutions or validated by a PCI SSC Qualified Security Assessor P2PE Company.

(Signature of Acquirer Executive Level Officer)

(Date)

(Acquirer Officer Name)

(Title)

Waiver is for PCI DSS validation exercise only and granted at Visa’s discretion. All merchants remain required to maintain PCI DSS compliance. Acquirers retain full responsibility for merchants’ PCI DSS compliance, as well as responsibility for any fees, fines or penalties, which may be applicable in the event of a data breach. Visa reserves the right to require full PCI DSS validation of compromised entities or any entity that is determined to present a risk to the Visa system. Waiver may be rescinded in the event participant is determined not to meet all program requirements.

Technology Innovation Program

Merchant PCI DSS Validation Waiver Application

Multiple Merchant TIP Application Listing: