PCI Compliance Exception Waiver Form
Submit your request for a PCI compliance exception. Please complete all fields accurately. Your waiver will be reviewed according to company policy.
Full Name
*
First Name
Last Name
Business Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Team
*
Company or Organization Name
*
Reason for PCI Exception Request
*
Describe the System or Business Process Involved
*
Requested Duration of Exception
*
Please Select
30 days
60 days
90 days
Other (please specify in Reason)
The Last 4 Digits of Your Credit Card (if applicable)
Submit Waiver Request
Should be Empty: