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Order PCI

Please fill out the form below as accurately as possible

Customer name (eg. Acme Corp.):    (Required)
Partner/reseller name (eg SecureTest Ltd):    (Required)
Customer's order number (Number used by Partner to track customer's order):    (Required)
Attach purchase order (Purchase order from Partner to netVigilance) :   
Order confirmation/invoice email address (Email at Partner who should recieve invoice from netVigilance eg [email protected]):    (Required)
Enduser contact name:    (Required)
Enduser contact phone:    (Required)
Enduser contact email:    (Required)
Email address for Scan start notifications (Should the notifications go the enduser or to
the partner):   
Date when the firewall/IPS will be open for first quarterly scan (mmm/dd/yy):    (Required)
First quarterly scan
Date when the firewall/IPS will be open for second quarterly scan (mmm/dd/yy):   
Second quarterly scan
Date when the firewall/IPS will be open for third quarterly scan (mmm/dd/yy):   
Third quarterly scan
Date when the firewall/IPS will be open for fourth quarterly scan (mmm/dd/yy):   
Fourth quarterly scan

Free Rescan

Customer is entitled to one free rescan to verify corrections on same IP scope within 30 days of being found non-compliant by a fully paid PCI ASV scan by netVigilance.
IPs to be scanned (eg '' NOT ' Firewall'):   
Scan options:    (Required)

Virtual Hostnames for web-server sharing the same IP cannot be accurately remotely determined, it is the customers responsibility to submit ALL virtual hostnames. From PCI Standard Requirement "PCI Scanning Procedures v1_1" page 2 section 3:
Prior to scanning the web site and IT infrastructure, merchants and service providers must:
• Provide the ASV with a list of all Internet-facing IP addresses and/or IP address ranges
• Provide the ASV with a list of all domains that should be scanned if domain-based virtual hosting is used

NOTE!: ALL virtual web-servers MUST be specified, not just the ones accepting creditcard.

HELP! - Additional detailed explanation of virtual host names
List of Virtual Hostnames (FQDN)(eg '' NOT ' web-server'):   
Customer verifies that ALL Fully Qualified Domain Names (FQDN) used for Virtual Hosting has been supplied, and acknowledges that they understand that missing FQDN INVALIDATES the scanning result at owners cost and risk :    (Required)

Originating IPs used by Scan.

To insure an accurate scanning result netVigilance will use many different tools and methods to scan Customer for PCI DSS compliance. - -
Customer positively confirms that the above IPs have been entered into ALL relevant systems, including: Intrusion Detection systems (IDS); Intrusion Prevention systems; Cisco Self Defending Networks, Cisco Outbreak Prevention, etc. :    (Required)
Load Balancers in front of Servers:    (Required)

Comment: Any information that you think could be useful for our handling of your request.   
Please type this number to verify human presence 8912 :    (Required)

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