Payment Card Renewal Checklist
This form MUST be Completed and returned back to the PCI Compliance Office 30 days prior to your annual anniversary date. Failure to complete and return to PCI Compliance Office may result your account being CLOSED. Upon receipt of your checklist and applicable documents the PCI office will determine if you meet the minimum standards to maintain an account.
Department Date
Merchant Identification Number (MID) Phone
Merchant Department Responsible Person
(MDRP) E-mail
If you maintain equipment, list the make, model and serial number(s):
Checklist
Has a review been completed of the VU Payment Card Processing and PCI Compliance Policy Procedure Manual within the last 12 months
Yes No
Has the departmental MDRP verified everyone who has access to the cardholder data environment and confirmed their Payment Card Security and Point of Sale training via Learning Exchange is complete? (This would include Anyone who has access to the Payment Processing environment. Including, but not limited to employees, contractors who may process on behalf of VU, IT staff who support the payment card application.)
Yes No
Is a copy of your departmental Payment Card Policy Procedures complete, signed and on file with the PCI Compliance Office?
Yes
If No, attach document
Is a copy of your current departmental Payment and Processing Network diagram included in your departmental Payment Card Policy Procedure document on file with the PCI Compliance Office?
Yes
If No, attach document
Is a copy of your current Incident Data Breach Response Plan included in your departmental Payment Card Policy Procedure document on file with the PCI Compliance Office?
Yes
If No, attach document
Has the MDRP completed your departmental Self Assessment Questionnaire (via Trustkeeper) and is a Signed Certification of Completion on file with the PCI Compliance Office?
Yes, attach Signed Certification of Completion If No, your MID is subject to be closed
Additional comments for PCI office: