DECLARATION

:": I hereby agree to the terms and conditions specifie<i in the Subscriber's Agreement form; that all information provided and documents submitted in
relation to this application is true and correct to the best of my knowledge; that I am duly authorized to make this application; that I consent to the
subscriber agreement and will abide by the same, that I accept the publication of my certificate information.

By submitting this form I hereby authorize and expressly give consent to the Registration Authorities (RA) and Cerlification Authorities (CA)
operating as part of the Philippine National PKI through its authorized representative(s) to view and verify my personal information from whatever
source it deems applicable.

Date: Place: Name of Applicant:

Signature:

CHECKLIST OF DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLICATION

Present one (1) copy and the original documents to our Registration Authority for verification and attestation

Required Documents:

Select One: tfl eirtn Certificate {J Passport Alien Certification of Registration

Select One: fi uurto Comptiant ffi otners

ln the absence of UMlD-compliant card, any two (2) of the following cards are allowed
. . Passport . . Rtien Certification of Registration i lmmigrant Certificate of
Registration
. . Driver's License
. . Professional Regulation Commission (PRC) ID ,;. Government ffice and GOCCC lD, e.g. Armed Forces of the philippines
(AFP ID), Home Development ftilutual Fund (HDlr/F lD)
^ . National Bureau of lnvestigation (NBl) Clearance : , Department of Social Welfare and Development (DSWD)
. : Postal lD
. : lntegrated Bar Of The Philippines lD
. . Voter's lD : Company lDs lssued by Private Entities or lnstitutions Registered with or
. . Government Service lnsurance System (GSIS) e-Card Supervised or Regulated either by the BSP, SEC or lC
'"" Social Security System (SSS) Card

. . Senior Citizen Card

: . Oversea Workers Welfare Administration (OWWA) lD
. :oFWrD
. . Seaman's Book
TO BE FILLED BY RA OFFICER ONLY
I declare that the applicant has provided correct information in this application form. I have checked and verified the application form and supporting
documents.

RA Code: Name:

RA Seal and
Signature:
Stamp

Date: Place:

DICT
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