APPLICATION FOR DIGITAL CERTIFICATE
Application ID Number (For Official Use only)
Instructions:
1. Please fill the form in BLOCK LETTERS ONLY.
2. Required fields are marked WITH AN ASTERISK (*).
3. Present one (1) copy and the original documents to our
Registration Authority for verification and attestation.
4. Any information that is not verified shall not be included in Affix recent passport
certificates. size (35x45mm)
5. Any discrepancy or inconsistency in the form will lead to photograph of the
delay and/or rejection. applicant
6. Put a CHECK ON THE BOX that corresponds to your answer.
7. Do NOT INPUT ABBREVIATED information or ACRONYMS.
1. CERTIFICATE CLASS
2. CERTIFICATE TYPE 3. METHOD OF ACTIVATION
1A 2A ✔ Signing
Individual
3A ✔ Online Download
2B Authentication
4. APPLICANT’S DETAILS
4A* Last
Name 4B* First 4C* Middle 4D* Name
Name Name Extension
(JR/SR/IIICALAOER
CALAOR JAIRUS LYLE TENIO
4E* Gender Male ✔ Female 4F* FILIPINO 4G* Date of 09/28/1990
Nationality Birth
(DD/MM/YYYY)
4H* TIN
486-191-186 4I SSS No.
4J GSIS No.
20049800 4K Philhealth 4L Pag-ibig
No. No.
60
4N Other IDs presented during face to face verification
4M CRN No.
4O* Organization / Agency /
Company DEPARTMENT OF EDUCATION - REGION X
4P* Organizational Unit / Department / Division SDO BUKIDNON - GAMOT INTEGRATED
SCHOOL
4Q Marital Status Single Married ✔ Widow
4R Employment Status Working ✔ Student Self-employed Unemployed Senior Citizen
Last Name
First Middle Name Birthdat Living / De-
Name Name e
Extensio (DD/MM/YYYY) ceased
n
(JR/SR/III)
4S Spouse Name
HABAS MARY 07/30/199 LIVING
GRACE FOREN
3
4T Mother’s
A LIVING
ANDRES ES
Maiden Name
4U Father’s
TENIO 3
07/16/196
Name A TIMBAN
CALAO G LIVING
CELSO
09/15/196
R 5
PAMIS
A
5. CONTACT DETAILS
Residential Address
5A* Unit/Room/House
No.
5B*
Street
BALANGAY 1B
5C* 5E* Province 5D* cipality/City 5F* Zip Code
POBLACION
Barangay
BUKIDNON Muni
DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101,
DICT-CB-F0- Philippines
07 +63 (02) 920-0101 [Link]
8715 QUEZO N
5G Landline
No.
5H* Mobile
No.
09351991109
5I* Official Work Email [Link]@[Link]. * PNPKI-related emails will be sent to this email address
Address ph
Office Address
5K Unit/Room/Floor 5L Building
No.
5M Street
SITIO 5N STA. FELOMINA
5O
Municipality/City
GAMOT Barangay BUKIDNON
5Q Zip Code
QUE 5P Province
ZON 5R Landline
8715 No.
PNPKI RA Form 2018-01A
Version 4 Date Revised August 2022
DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101,
DICT-CB-F0- Philippines
07 +63 (02) 920-0101 [Link]
6. DECLARATION
I hereby agree that I have read and understood the provisions of the Subscriber ’s Agreement; 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.
I authorize and expressly give consent to the National PKI through its authorized representative(s) to verify my personal
information from whatever source it deems appropriate.
Date: 01/06/2024 Place: QUEZON, BUKIDNON Name of Applicant: JAIRUS LYLE T. CALAOR
Signature:
7. CHECKLIST OF DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLICATION
Present the ff. original documents with photocopy to our Registration Authority for verification and
attestation
Required Documents:
✔ Philippine National ID (PhilID) only
In the absence of National ID (PhilID), provide any two (2) of the following Documents or ID’s:
Birth certificate OR valid Passport
Unified Multi-purpose Identification Card (UMID) Compliant
Card Alien Certificate of Registration (ACR) card for
foreigners
In the absence of UMID Compliant card, any two (2) of the following cards are allowed as valid ID’s:
LTO Driver’s License
✔ Professional Regulation Commission (PRC) ID
National Bureau of Investigation (NBI)
Clearance Police Clearance Certificate
Postal Identity
Card COMELEC
Voter’s ID
Government Service Insurance System (GSIS) e-Card
Government Office and GOCC ID, e.g. Armed Forces of the Philippines (AFP ID), Home Development Mutual Fund
(HDMF) Social Security System (SSS) Card
Senior Citizen Card
Certification from the National Council for the Welfare of Disabled Persons
(NCWDP) Overseas Workers Welfare Administration (OWWA) ID / Overseas Filipino
Worker (OFW) ID Seaman’s Book
Alien Certification of Registration/Immigrant Certificate of
Registration Integrated Bar Of The Philippines ID
Department of Social Welfare and Development (DSWD) Certification
Company IDs Issued by Private Entities or Institutions Registered with or Supervised or Regulated either by the BSP,
SEC, or IC
8. DISCLAIMER
The collected personal information is utilized solely for documentation and processing purposes within the DICT and is
not shared with any outside parties, in accordance with the Data Privacy Act of 2012.
TO BE FILLED BY RA OFFICE 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: JAIRUS LYLE [Link]
Signature: RA Seal and
Stamp
Date: 01/06/2024 Place: QUEZON, BUKIDNON
THIS FORM IS NOT FOR SALE
DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101,
DICT-CB-F0- Philippines
07 +63 (02) 920-0101 [Link]
SUBSCRIBER AGREEMENT
PLEASE READ THIS AGREEMENT CAREFULLY BEFORE USING THE DIGITAL CERTIFICATE ISSUED TO YOU OR
YOUR ORGANIZATION. BY APPLYING FOR A DIGITAL CERTIFICATE, YOU ARE AGREEING TO BE BOUND BY
THE TERMS OF THIS AGREEMENT. IF YOU HAVE PROBLEMS UNDERSTANDING THIS AGREEMENT, E-MAIL
US AT
[Link]@[Link].
1.0 Definitions
Applicant:The individual that applies for (or seeks renewal of) a Digital Certificate naming it as the “ Subject”.
Certification Practice Statement - A statement of the practices that a certification authority employs in
(CPS)
issuing, managing, revoking, and renewing or re-keying certificates.
Certificate Policy - A named set of rules that indicate s the applicability of a certificate to a particular
(CP)
community and/or class of application with common security requirements. For example, a particular CP
might indicate applicability of a type of certificate to the authentication of parties engaging in business-
to-business transactions for the trading ofgoods or services within a given price range.
Certificate Revocation List ("CRL") - A collection of electronic data containing the list of serial numbers
revoked or suspended by the Certificate Authority
Online Certificate Status Protocol ("OCSP") - An Internet Protocol (IP) used to obtain the real time
revocation status of a digital certificate. It is used as an online faster alternative to CRL list.
Public Key - A mathematical key which is available publicly and which is used to verify Digital Signatures
created with the matched Private Key and to encrypt electronic data which can only be decrypted using
the matched Private Key
Private Key - A mathematical key which is kept private to the owner and which is used to create Digital
Signatures or to decrypt electronic data
Registration Authority (RA) - An entity that is responsible for one or more of the following functions: the
identification and authentication of certificate applicants, the approval or rejection of certificate
applications, initiating certificate revocations or suspensions under certain circumstances, processing
subscriber requests to revoke or suspend their certificates, and approving or rejecting requests by
subscribers to renew or re-key their certificates. RAs, however, do not sign or issue certificates (i.e., an
RA is delegated certain tasks on behalf of a CA).
Subscriber - A subject of a certificate who is issued a certificate.
2.0 Authority to Use Digital Certificates
2.1 Grant of Authority As from the Effective Date up to the validity period of any issued Digital Certificate
("Valid from" date to "Valid to" date ) , PNPKI grants to the Subscriber the authority to use the requested
Digital Certificate in conjunction with Private Key and/or Public Key operations. The obligations of the
subscriber (see section 4.0) with respect to Private Key protection are applicable from the effective date.
2.2 Limitations on Authority The digital certificate cannot be used for purposes other than what is allowed
in this Sub- scriber Agreement and the CPS.
3.0 Use of PNPKI Digital Certificate
The subscriber shall use the certificate for its lawful and intended use only. The certificate shall be used
in accordance with its Key-Usage field extensions. All issued certificate by PNPKI cannot be used for
purposes other than what is allowed in this subscriber agreement and by the CPS. PNPKI shall not be
liable for any claims arising from prohibited use.
3.1 Acceptance of a Digital Certificate
The following conduct constitutes certificate acceptance:
a) A certificate shall be deemed accepted when it is in the subscriber or representative’s control;
b) Failure of the subscriber to object to the certificate or its content within five (5) calendar days; or
c) The subscriber uses the certificate.
3.2 Revocation of Digital Certificates
A certificate shall be revoked when the bind between the subject and the subject’s public key is no
longer valid. An end-user subscriber certificate can be requested for revocation under any of the
following conditions:
a) When a verified request for revocation is received by PNPKI CA or RA;
b) When any of the information found in the certificate is changed or no longer applicable;
c) When the Private Key, or the media holding the Private Key, associated with the certificate is
compromised;
d) When the PNPKI CA determines that the end-user entity is no longer complying with the
DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101,
DICT-CB-F0- Philippines
07 +63 (02) 920-0101 [Link]
requirements of by the CPS and this subscriber agreement ; or
e) When the PNPKI CA has the reason to believe that the certificate was issued in a manner that is not
in accordance with the procedures required by the CPS and this subscriber agreement.
f) When subscriber requested revocation of the Certificate;
DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101,
DICT-CB-F0- Philippines
07 +63 (02) 920-0101 [Link]
4.0 Subscriber Obligations
This Agreement governs the subscriber’s application for, acceptance, and use of, a digital certificate issued by the
RA.
a) The provisions of the Root CA CP/CPS, GovCA CP/CPS, and other pertinent documents are binding
upon the subscriber.
b) All the information provided in the digital certificate application form is true and correct.
c) The use of the digital certificate shall be for the sole use of the subscriber.
d) The subscriber will not, under any circumstances, allow any other person to use the digital
certificate. Any such use by another person constitutes a compromise of the associated private
key, requiring the revocation of the digital certificate.
e) The subscriber shall protect the confidentiality of the private key associated with his or her digital
certificate as well as any PIN number or other means used to activate the private key.
f) The subscriber shall remain solely responsible for the maintenance of the confidentiality of the
certificate.
g) The subscriber shall not use the digital certificate for any unlawful purpose, or for any purpose that
does not have anything to do with accessing the PKI information systems or transactions using the
digital certificates.
h) The subscriber shall promptly request the RA to revoke the digital certificate upon knowing or
suspecting inaccurate information, loss, exposure or compromise of the associated private key.
i) The subscriber shall not tamper, interfere with, or reverse-engineer any technical implementation of
the digital certificate or its use, or in any manner seek to compromise the security provided by the
RA and the National PKI system.
j) The subscriber accepts the risk of an undetected compromised digital certificate or associated
private key, which may be used to impersonate the said subscriber.
5.0 Permission to Publish Information
The Subscriber agrees that PNPKI may publish the serial number of the Subscriber’s Digital Certificate in
connection with PNPKI’s dissemination of CRL’s and OCSP.
6.0 Disclaimer
PNPKI shall not be liable for any claims arising from prohibited use of Digital Certificates issued by GovCA.
PNPKI will not be liable if the user has not respected his obligations mentioned in the CPS and in this
agreement.
7.0 Term and Termination
This agreement shall terminate upon
a) The expiry date of any Digital Certificate issued to the Subscriber
b) Any failure to comply with any of the subscriber obligations mentioned in this Subscriber Agreement
8.0 Effect of termination
Upon termination of this Subscriber Agreement for any reason, PNPKI may revoke the Subscriber’s Digital
Certificate in accordance with PNPKI revocation procedures.
9.0 CP and CPS Information
The digital certificate contains information provided by the subscriber, which is authenticated by the RA in
accordance with the requirements set out in the CA CP and CPS, available for viewing and download at
[Link]/pnpki/.
Date: 01/06/2024 Place: QUEZON, BUKIDNON Name of Applicant: PJAIRUS LYLE T. CALAOR
Signature:
(Please sign in the presence of an administering officer)
DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101,
DICT-CB-F0- Philippines
07 +63 (02) 920-0101 [Link]
