| Vendor Name: |
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| Contact: |
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| Telephone: |
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| Email: |
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| Application Name: |
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| Version: |
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Other Certifications:
(i.e. PCI, HIPAA) |
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| Request Date/Time: |
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| Method of Test: |
Test account/ user Online Meeting |
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Other: |
| Methods to Test: (check all that apply) |
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| Would you like to become a Partner after Certification? Yes No |
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| By submitting this application form to Skipjack, I certify that: |
| The application does not store credit card data |
| The application does store credit card data but is certified with the Payment Card Industry (PCI) Data Security Standard |
| The application does store credit card data but is not certified with the Payment Card Industry (PCI) Data Security Standard |
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