Internet Privacy Statement Program: Application

SECURE APPLICATION FOR PrivacySecure®, Inc. SEAL ! READ THIS FIRST ! ALL fields are required unless otherwise noted.
COMPANY PROFILE
Company: Legal Name:
Company: Business Name:	Your company name as you would like it to appear on the certification page. (i.e., Your Company name as used on the Internet)
Headquarters Address:
	(not required)
City:
State:
ZIP Code:
Main Phone:
Main Fax:	(not required)
Primary Website Address:
Primary Email:
Number of Full-time employees:	(For part-time use total full-time equivalents.)
Month and year business began:
Description of your company (limit 500 characters-html OK): (as you would like it to appear in the participant search)
Is your company a current member of the Better Business Bureau? Yes No
Does your company have a DUNS number? (Click here to check with Dun & Bradstreet) Yes No
If yes, what is your company's DUNS number? (not required)
Does your company a have an online privacy policy? (Required before application will be approved) Yes No
URL of your Privacy Policy:
Separate processing and annual fees may be charged for applicants submitting an application for multiple websites with privacy policies and information practices of such substantive difference that they require multiple compliance assessment reviews. In such instances, PrivacySecure®, Inc. will notify participants of the total costs prior to processing the application. Does this application cover more than one website or online service? Yes No
Are all the websites or online services covered by a common privacy policy? (If not, please submit a separate application for each privacy statement.) Yes No
Any seal participant whose website or online service is directed to children under the age of 13, or who collects individually identifiable information from particular online visitors actually know to be children under the age of 13, must complete the Children's Supplemental Assessment Questionnaire in addition to the compliance Assessment document. Will you be completing the Children's Supplemental Assessment Questionnaire? (If yes, we will send this statement to you separately. There will be a small additional fee.) Yes No

ALL fields are required unless otherwise noted.
COMPANY CONTACT FOR PRIVACY POLICY
Contact Full Name:
Contact Title:
Address:	(Write "same" if the same as address entered above.)
	(not required)
City:
State:
ZIP Code:
Phone Number:
Ext.	(not required)
Fax Number:	(not required)
Email:	Please enter your email address here even the same as above. This email will be used for all correspondence.
Second Contact Name	(If only one owner, write "same")
Second Contact Title	(e.g., Vice Pres.)
Second Contact email
Date Business Began
In the space below, write any questions you have or other information you would like considered with your application.
(not required)

ACCESS INFORMATION
If your website has any individual pages or sections covered by the privacy policy which require a fee or other restricted access mechanism (excluding free registration), PrivacySecure®, Inc. will require access as part of the compliance review. To accommodate this process, please set up a "dummy" or "test" account which will allow PrivacySecure®, Inc. access to this portion of the website or online service. Although you may choose to deactivate or erase this account after the seal has been awarded, PrivacySecure®, Inc. reserves the right to request a new account at any time during the display of the seal to ensure ongoing compliance.
The covered URLs do not have any fee-based restricted access pages
The covered URLs have fee-based restricted access pages, a test account has been set up as: (required if applicable)
Username/ID:
Password:

ALL fields are required unless otherwise noted.
APPLICATION AUTHORIZATION
Please list the name and title of the company officer who has authorized your company to apply for a PrivacySecure® privacy seal. Note, the individual named here must sign the license agreement.
Authorized Individual:
Title:
Email:

Payment will be requested after your application has been reviewed and before a PrivacySecure® Certificate will be issued.