Written Information Security Program (Wisp) For Protection Of Personal Information Template Page 11
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11____________________, INC.
ACKNOWLEDGEMENT AND CERTIFICATION
(Third Party Service Providers)
I hereby certify that my company has instituted (if I am not part of a company, that I have
instituted) Personal Information security measures in compliance with Massachusetts
General Laws c. 93H and 201 Code of Mass. Regulations 17.00, and that my company’s
business operations (my business operations, if I am not part of a company) are in
compliance with these legal requirements with respect to Personal Information to which
the client Corporation has granted my company access (has granted me access, if I am not
part of a company).
I acknowledge that if I have any questions regarding the Corporation’s WISP or related
policies, procedures, standards or guidelines, it is my responsibility to address those
issues with the Corporation’s Data Security Coordinator for clarification.
I acknowledge that failure on my part to practice due care and due diligence with respect
to Personal Information and the Corporation’s WISP may result in the termination of my
(and my company’s) service arrangement with the Corporation for cause.
The terms of this acknowledgement shall survive any termination of service.
________________________________________
NAME (PRINTED)
________________________________________
COMPANY NAME (PRINTED)
__________________________________________
SIGNATURE
Date: ______________ , 20___
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