DutchGrid Certification Authorities Registration

Reserved for CA operations use ........ - ......
/O=dutchgrid/O=users/O=somewhere/CN=John Doe
□ ID Document valid □ PoP Challenge verified □ RA Signature OK
Surname
Doe
Given names
John
Place of Birth
Someplace
Date of birth
01 Jan 1900
Identity paper type, number, country
Passport NL12345678, NL
SOFI number (optional)

Send this form by mail or fax to

DutchGrid MS CA NIKHEF c/o Someone P.O. Box 12345 NL 1009 DB Amsterdam The Netherlands fax: +31 20 592 5155

The first twenty (20) characters of your proof-of-possession challenge:

0123456789ABCDEF0123

Contact Information

Name
John Doe
Streed addres (physical delivery address)
Bar avenue 0
Organisation
Foo inc.
ZIP code
1234AA
Phone number
+31 (0)123 456789
Place (and province where applicable)
Heaven
Email address
john@heaven.mil

Signature

I have filled all data truthfully and to the best of my knowledge, and will abide by the certificate policy and practice statement of the DutchGrid Certification Authority.
Signature
Place and date


Reserved for RA operations use
I, RA name have verified the identity of the requester based on the identity piece listed above, and confirm that the information is complete and accurate. I met the applicant in person on date and time of meeting at meeting place and have confirmed his affiliation with organisation name to the extent required in the certificate policy and practice statement.
Notes Signature of registration authority