REQUEST FOR VERIFICATION PHONE CALL Please sign and scan this document and deliver to the Registration

Authority for processing. You can upload via your request console or email to ra@starfieldtech.com
Please allow up to 2 business days for an initial response.
**Please Note** Common Name refers to the Exact Domain URL, Host Name or Code Signing Publisher Name for which the Secure Certificate is being Requested.

Common Name of Certificate:

___________________________________________________________________________________
Applicant’s Exact Company or DBA Name:

___________________________________________________________________________________
Corporate Contact First and Last Name:

___________________________________________________________________________________
Current Email Address:

___________________________________________________________________________________

Company Contact’s Phone Number for Verification Call:
[area code + phone] _____________________________________________

Important: Identification Documentation Required: 1) A copy of a current government issued photo ID of the signer of this document. (driver’s license, state/federal/military ID or passport) 2) A copy of an original document indicating proof-of-right to do business for the exact company name listed above. The following documents will be accepted:
     Business license Sales & Use Tax certificate “Doing Business As” documentation Fictitious Name documentation Articles of Incorporation  Occupational Tax Certificate/License  Non-profit Organization Tax Exemption Certificate  Charter documentation  Partnership Agreement documentation NOTE: Fed. ID Number documents are not acceptable

I certify and affirm that I am the duly authorized representative of the company applying for said Secure Certificate AND that I am also a duly authorized representative of the company who can give permission to have the above number called. I agree that neither Starfield Technologies, Inc. nor any of its affiliates shall be liable to me or any other party in any amount for any actions taken pursuant to this request. I hereby waive and release any and all claims related to this request asserted against Starfield Technologies, Inc. or any of its affiliates. Additionally, I agree to defend, indemnify, and hold harmless Starfield Technologies, Inc. and its affiliates for any loss, liability, damages or expenses, including reasonable attorney’s fees, resulting from third party claim, action or demand related to this request, this authorization, or any actions taken by Starfield Technologies, Inc. in connection therewith.
Signed: ______________________________________________________ Date: ____________________________

Printed Name: _____________________________________________________________________________________

Starfield Technologies, Inc.

Authorized Phone Verification 2009 v. 1.0

10/5/2009

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