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. Affix
recent passport size 4.Any information that is not verified shall not be included in
certificates. ( 3 5 x 4 5
delay and/or the applicant
rejection.

1. CERTIFICATE CLASS 2. CERTIFICATE TYPE 3. METHOD OF ACTIVATION

2A Signing 3A USB Token
1A Individual
2B Authentication 3B Online Download
4. APPLICANT’S DETAILS
4A* Last Name 4B* First Name 4C* Middle Name 4D* Name Extension (JR/SR/III)

ABRIGONDO ORLAN CABALUNA

4E* Gender Male Female 4F* Nationality 4G* Date of Birth

(DD/MM/YYYY) 17-09-1993
FILIPINO
4H* TIN 312-430-646-000 4I SSS No. 06-3305102-8

4J GSIS No. 0020-0565-5395 4K Philhealth No. 12-051131512-9 4L Pag-ibig No. 1211-9916-4200

0111-1723821-4 4N Other IDs presented during face to face verification PRC ID # 1700688
4M CRN No.
4O* Organization / Agency / Company DEPARTMENT OF EDUCATION – CEBU CITY DIVISION

4P* Organizational Unit / Department / Division DEPARTMENT OF EDUCATION – CEBU CITY DIVISION

4Q Marital Status Single Married Widow

4R Employment Status Working Student Self-employed Unemployed Senior Citizen
Last Name First Name Middle Name Name Birthdate Living / De- ceased
Extension (DD/MM/YYYY)
(JR/SR/III)

4S Spouse Name NONE

4T Mother’s Maiden
CABALUNA ALMA PARDILLO 21-12-1964 LIVING
Name
ABREGONDO RONIE CASETAY 29-09-1967 LIVING
4U Father’s Name
5. CONTACT DETAILS
Residential Address
5A* Unit/Room/House No. BLOCK 24 LOT 1 5B* Street CABANGCALAN 1

5C* Barangay BULACAO 5D* Municipality/City CEBU CITY

5E* Province CEBU 5F* Zip Code 6000

5G Landline No. NONE 5H* Mobile No. 0945-437-8679

5I* Email Address [email protected] 5J Alternate Email Address [email protected]

Office Address
5K Unit/Room/Floor No. 5L Building
5M Street NEW IMUS ROAD 5N Barangay DAY-AS

5O Municipality/City CEBU CITY 5P Province CEBU

5Q Zip Code 6000 5R Landline No. 032-2551516

5S Email Address [email protected] 5T Fax No.

PNPKI RA Form 2018-01A
Date Revised February 2020

DICT Building, C.P. Garcia Avenue, Diliman, Quezon City, 1101, Philippines
+63 (02) 920-0101 www.dict.gov.ph
 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: JUNE 23, 2021 Place: CEBU CITY Name of Applicant: ORLAN C. ABRIGONDO

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:
Birth certificate issued by PSA OR valid Passport
Alien Certificate of Registration (ACR) card for foreigners
Unified Multi-purpose Identification Card (UMID) Compliant Card
In the absence of UMID-compliant card, any two (2) of the following cards are allowed as valid ID’s
Driver’s License
Professional Regulation Commission (PRC) ID
National Bureau of Investigation (NBI) Clearance
Postal ID
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
Overseas Workers Welfare Administration (OWWA) ID
OFW ID
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:
Signature: RA Seal and
Stamp
Date: Place:

THIS FORM IS NOT FOR SALE

 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
[email protected].
1.0 Definitions
Applicant:The individual that applies for (or seeks renewal of) a Digital Certificate naming it as the “ Subject”.
Certification Practice Statement (CPS) - A statement of the practices that a certification authority employs in issuing,
managing, revoking, and renewing or re-keying certificates.
Certificate Policy (CP) - A named set of rules that indicate s the applicability of a certificate to a particular 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.
2.1 Authority to Use Digital Certificates
2.2 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.
2.3 Limitations on Authority The digital certificate cannot be used for purposes other than what is allowed in this Sub-
scriber Agreement and the CPS.
3.1 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.
3.2 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.

3.3 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 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;
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.
7.1 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 dict.gov.ph/pnpki/.

Date: Place: Name of Applicant:

Signature:
(Please sign in the presence of an administering officer)