Pdf application for non piv certificate

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Author: Buddy Robinson
Creator: Microsoft Word 2010
Producer: Microsoft Word 2010
CreationDate: Fri May 29 11:09:44 2015
ModDate: Wed Jun 5 07:52:07 2019
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Form: AcroForm
Pages: 2
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Page size: 612 x 792 pts (letter) (rotated 0 degrees)
File size: 287628 bytes
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PDF version: 1.6

  • APPLICATION FOR CANCELLATION OF CERTIFICATE ... - PennDOT Home
  • PDF Application for non-PIV Certificate
  • PDF Application for Oklahoma School Certificate

PDF Application for Oklahoma School Certificate

Sensitive But Unclassified
Application for non-PIV Certificate
Employees, contractors, and affiliates of the Department of the Treasury must agree to the terms of this
agreement to receive a Treasury-issued digital certificate. This applies to certificates assigned to the
applicant or device certificates sponsored by the applicant. Applicants are bound to the terms of this
document for the lifetime of the certificate.
Restricted Use: These certificates are the property of the United States Government. Illegal or unauthorized use
of these certificates is punishable by law. This certificate must never be used to protect classified data.
Sponsors: Sponsors submit applications in behalf of devices such as Web servers, Microsoft Domain Controllers,
routers or other devices. Sponsors are liable for the proper use of the certificate. Sponsors provide a fully qualified
host name, a group email address for the administration team, and other information about the device. The email
address allows the CA to contact administrators.
Use of Approved Encryption Algorithms: Acceptable encryption algorithms in order of preference are AES-
256, AES-192, AES-128 or 3DES, as specified in the NIST Federal Information Processing Standard (FIPS)
Publication 140.
Accuracy of Representation: Information submitted to the CA must be complete, accurate, and truthful. Notify
your Registration Authority, Local Registration Authority or Trusted Agent of changes to information contained in
the certificate.
Protection of Private Keys: Subscribers must follow the directions contained in the CA's Certificate Policy and
Registration Practice Statement to protect the private keys associated with the certificate.
Notification of Forgotten Password, Profile Loss, Disclosure, or Compromise: Upon actual or suspected loss,
disclosure, or compromise of a private cryptographic key, unused activation codes, or a cryptographic profile's
password, notify your Registration Authority, Local Registration Authority, or Trusted Agent immediately.
Non-Transference of License: You may not transfer your certificate or software to any other person.
Revocation: If you no longer need a certificate, or it has been compromised, notify your Treasury Security
Officer, Registration Authority, Local Registration Authority, or Trusted Agent as soon as possible requesting
revocation.
Export Laws: Notify your Registration Authority, Local Registration Authority, or Trusted Agent if you have
business requirements involving encryption for someone outside the United States or a foreign national within the
United States.
Revocation Data: Subscribers to Treasury maintained CAs must use Certificate Revocation Lists (CRL), root
certificates, and issuer certificates from Treasury repositories, i.e., pki. (HTTP), ldap. (LDAP),
and ocsp. (OCSP).
Your signature on the next page indicates your understanding and acceptance of the terms of this
agreement by signing below. This agreement is applicable for the lifetime of the certificate.
Sensitive But Unclassified
TD F 81-01.5
(06/2019)
Page 1 of 2
Sensitive But Unclassified
Applicant Phone Number(s):
Applicant Work Address:
Common name: CN=
(CN is required to be a DNS SAN)
Email (Group E-Mail for devices) Address:
Additional SubjectAltName(s):
(optional) Examples include MS GUID (domain controllers), DNS name(s), IP address(es), and User Principal Name.
Certification Authority: Certificate Type: Action:
TOCA PROD Web Browser Create New Certificate
TOCA DEV Device or Server Perform Key Recovery
FSCA PROD Device or Server Revoke Certificate
with Client and Server OIDS
FSCA DEV Domain Controller Reason:
RA Credential
Special Instructions (optional):
Name (Printed) Date Digital Signature (PIV)
Email the completed and digitally signed form to your Bureau RA.
(This section is to be completed by the Registration Authority)
Do not write below this line.
Identify Proofing
Date:
Applicant's Identification #1:
Applicant's name as it appears on ID#1:
Applicant's Identification #2:
Applicant's name as it appears on ID#2:
Registration Authority (RA) Name:
RA's Digital Signature (PIV):
(Identity verification: (1) PIV credential used to digitally sign this application or (2) a Federally issued credential and a State issued credential recorded by the RA)
Sensitive But Unclassified
TD F 81-01.5
(06/2019)
Page 2 of 2

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