Premium EV SSL Certificate Request No

CERTUM - Powszechne Centrum Certyfikacji
Unizeto Technologies S.A., ul. Królowej Korony Polskiej 21, 70-486 Szczecin; Korespondencja: ul. Bajeczna 13, 71-838 Szczecin, tel. +48 91 4257440, fax +48 91 4257422, Sąd
Rejonowy Szczecin-Centrum, XIII Wydział Gospodarczy KRS w Szczecinie nr KRS 00000233499, NIP: 852-000-64-44, Kapitał zakładowy: 5 600 000 zł (wpłacony w całości)
Premium EV SSL Certificate Request No ..............................
to the Subscriber Agreement No
/CTN/20.....
SUBSCRIBER INFORMATION
1. This information will be included in the EV SSL certificate:
1. Entity Name (Legal Name):
2. Domain Name:
3. Subscriber Address Details:
Street Address:
City:
State/province:
Postal code:
Country:
4. Incorporation or registration jurisdiction:
City (if any):
State/province (if any):
Country:
*
5. Registration number:
The requester is acting on behalf of another natural person, company, organization or public
authority.
*
Specific Registration Number assigned to the Subscriber by the Incorporating or Registration Agency in the
Subscriber’s Jurisdiction of Incorporation or Registration.
Certificate Request, Page 1 from 2
CERTUM - Powszechne Centrum Certyfikacji
Unizeto Technologies S.A., ul. Królowej Korony Polskiej 21, 70-486 Szczecin; Korespondencja: ul. Bajeczna 13, 71-838 Szczecin, tel. +48 91 4257440, fax +48 91 4257422, Sąd
Rejonowy Szczecin-Centrum, XIII Wydział Gospodarczy KRS w Szczecinie nr KRS 00000233499, NIP: 852-000-64-44, Kapitał zakładowy: 5 600 000 zł (wpłacony w całości)
CONTACT DETAILS
2. The identity of the persons representing the Subscriber:
CERTIFICATE REQUESTER:
The Certificate Requester represents and binds Subscriber in its certificate procurement process
with respect to completing and submitting Certificate Requests on behalf of Subscriber.
A Certificate Requester is a natural person who is employed by the Subscriber, or an authorized
agent who has express authority to represent the Subscriber or a third party that completes and
submits an EV Certificate Request on behalf of the Subscriber.
Full Name of Certificate Requester:
Title of Certificate Requester:
E-mail address of Certificate Requester:
AFFIRMATION
1. I, the undersigned Certificate Requester, declare under penalty of perjury that the information set
forth in this Certificate Request to the CERTUM is true, complete, and accurate. Therefore I am
obliged to immediately inform CERTUM about any errors, defects or changes in the EV SSL
certificate. Failure to meet these requirements may result in termination of the contract, certificate
revocation or suspension and taking legal action against t me and / or the company I represent.
2. Acting on behalf of the SubscriberI hereby authorize CERTUM to verify the information contained in
the Certificate Request in accordance with the rules set in the Guidelines for the Issuance and
Management of Extended Validation Certificates published on http://www.cabforum.org. I hereby
accept the Subscriber Agreement.
3. I hereby affirm that my personal details provided in my request for the issuing of a certificate are
correct and true and I agree that Unizeto Technologies SA, ul. Królowej Korony Polskiej 21, 70-486
Szczecin, may store and process this information in accordance with the Privacy Protection Law of
29/08/1997 (Journal of Laws No. 133/1997, item 833). This information is required for the
accomplishment of the certification process described in the Certification Procedure Code. Further, I
consent to the publication of my certificate containing my personal details in the repository of
CERTUM - Powszechne Centrum Certyfikacji.
______________________________
Certificate Requester
__________________
Date
Certificate Request, Page 2 from 2