PCI DSS Authorization to Test - Piratica, LLC - Information Security, Risk Management

PCI DSS Authorization to Test

Requested Test

Organization Name *

Legal Name of the Organization to be Tested

Name of Requestor *

First and Last Name

Position of Requestor *

Position or Job Title of Requestor

Email *

Primary Contat Phone *

Shipping Address *

Shipping Address (additional)

City *

Zip / Postal Code

Electronic Signature
I warrant that my full legal name is listed as "Requestor Name" and that I am authorized by the organization listed as "Organization Name" to request the tests listed in "Requested Test".

I understand that Piratica will contact me to schedule the test.

I understand that I am responsible for returning the scanning appliance, using the original shipping container and provided pre-paid shipping label within 48 hours of notification that the test is complete. Failure to do so may result in additional charges.

I understand that I am responsible for returning the scanning appliance in like similar condition as I received it. Failure to do so may result in additional charges.

Checkboxes *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

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