Fillable GPO - PKI Registration Form V1-3

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GPO - PKI Registration Form V1-3

On average this form takes 10 minutes to complete

The GPO - PKI Registration Form V1-3 form is 1 page long and contains:

  • 3 signatures
  • 6 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

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GPO PKI Registration Form SECTION 1 (This section to be completed by applicant prior to in-person Registration)
USER INFORMATION
First Name
Middle Name
Last Name
Email Address
Telephone#
User’s Agency Name:
User’s Address:
Agency Badge
ID#
Other Fed. Gov’t-issued Picture ID
Type
ID#
Drivers License
State
ID#
Other Non-Fed. Gov’t-issued Picture ID or ID
Type
ID#
Supervisor Signature:
I declare under penalty of perjury that the foregoing is true and correct.
Executed on: __________________(date) Signature: _______________________________________
Supervisor Name:
SECTION 2. (This section to be completed by Registration Authority and User at time of Registration)
RA INFORMATION
RA First Name
RA Last Name
RA Telephone #
RA Email Address
Date of Registration Request
Date:
PKI Credential Issuance Completed Yes No
Date and Time:
Identification verified
Yes No If No do not proceed.
PKI Credential Type (software or smartcard)
Software (.epf file) Smartcard/Token
Smartcard/Token Type (if smartcard/Token credential):
(vendor and model number)
Smartcard/Token Serial Number:
(if smartcard/Token credential)
User Name (CN)
User Signature
I declare under penalty of perjury that the foregoing is true and correct.
Executed on: _________________(date) Signature: _______________________________________
RA Signature
I declare under penalty of perjury that the foregoing is true and correct.
Executed on: _________________(date) Signature: _______________________________________
Enter Date
Enter Supervisor Name from PKI Memorandum
Enter User First Name
Enter Middle Name or
"No Middle Name"
Enter User Last Name
Enter User Email Address
Enter User Telephone
Enter Agency Name
Enter User Address
Enter LRA First Name
Enter LRA Phone Number
Enter LRA Last Name
Enter LRA Email
Enter Date
Enter Date and Time
Enter Common Name for User (Usually FirstName LastName)
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GPO - PKI Registration Form V1-3

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Completed 26 May 2020

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