PCI Security Standards Council®

Qualified Integrators and Resellers ™

Legal Company Name
Business Address
Country Postal Code
Are you a Participating Organization? Yes No
How many QIR employees do you anticipate will attend training from your company?
Please tell us how you learned about the QIR training program :
Primary Contact (Applicant’s sole point of contact with PCI SSC’s QIR Program Manager)
As appears on government-issued ID.
Telephone E-mail

Please review the New Application Process Checklist to prepare. It can be found as Appendix B of the Qualification Requirements.