Subscriber: (1) TYPE (2) Number (1) TYPE (2) Number
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PramedicaPerdanaPutraSubscriber: (1) TYPE (2) Number (1) TYPE (2) Number
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PramedicaPerdanaPutraDEPARTMENT OF DEFENSE (DOD) PUBLIC KEY INFRASTRUCTURE (PKI)
SUBSCRIBER
CERTIFICATE OF ACCEPTANCE AND ACKNOWLEDGEMENT OF RESPONSIBILITIES
1. CERTIFICATE ACCEPTED BY
a. NAME (Typed or printed) (Last, First, Middle Initial) b. UNIQUE IDENTIFICATION (e.g., EDIPI, UID)
c. ORGANIZATION d. TELEPHONE NUMBER (Include e. E-MAIL ADDRESS
Area Code)
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulation; 44 U.S.C. 3101.
PRINCIPAL PURPOSE(S): To collect personal identifiers during the certification registration process, to ensure positive
identification of the subscriber who signs this form.
ROUTINE USES: Information is used in the DOD PKI certificate registration process.
DISCLOSURE: Voluntary; however, failure to provide the information may result in denial of issuance of a token containing
PKI private keys.
You have been authorized to receive one or more private and public key pairs and associated certificates. A private key
enables you to digitally sign documents and messages and identify yourself to gain access to systems. You may have
another private key to decrypt data such as encrypted messages. People and electronic systems inside and outside the DoD
will use public keys associated with your private keys to verify your digital signature, or to verify your identity when you
attempt to authenticate to systems, or to encrypt data sent to you. The certificates and private keys will be issued on a
token, for example a Common Access Card (CAC), another hardware token, or a floppy disk. The certificates and private
keys on your token are government property and may be used for official purposes only.
Acknowledgement of Responsibilities: I acknowledge receiving my PKI private keys and will comply with the following
obligations:
- I will use my certificates and private keys only for official purposes;
- I will comply with the instructions described to me today for selecting a Personal Identification Number (PIN) or other
required method for controlling access to my private keys and will not disclose same to anyone, leave it where it might
be observed, nor write it on the token itself;
- I understand that if I receive key management (encryption/decryption) key pairs on my token, copies of the private
decryption keys have been provided to the key recovery database in case they need to be recovered; and
- I will report any compromise (e.g., loss, suspected or known unauthorized use, misplacement, etc.) of my PIN or token to
my supervisor, security officer, Certification Authority (CA), Registration Authority (RA), Local Registration Authority
(LRA), Trusted Agent (TA), or Verifying Official (VO), immediately.
Liability: I will have no claim against the DoD arising from use of the Subscriber's certificates, the key recovery process, or a
Certification Authority's (CA's) determination to terminate or revoke a certificate. The DoD is not liable for any losses,
including direct or indirect, incidental, consequential, special, or punitive damages, arising out of or relating to any certificate
issued by a DoD CA.
Governing Law: DoD Public Key Certificates shall be governed by the laws of the United States of America.
f. IDENTIFICATION 1 g. IDENTIFICATION 2
(1) TYPE (DoD ID, Passport, etc.) (2) NUMBER (1) TYPE (DoD ID, Passport, etc.) (2) NUMBER
h. SUBSCRIBER'S SIGNATURE (The signature provided may be a digital signature if a good fingerprint i. DATE SIGNED (YYYYMMMDD)
or other adequate biometric has been collected. Otherwise the subscriber must provide a handwritten
signature.)
2. REGISTRATION OFFICIAL PER CPS
I have personally verified the identity of the person above in accordance with the applicable CPS and have personally
witnessed that person sign the form.
a. NAME (Typed or printed) (Last, First, Middle Initial) b. ORGANIZATION
c. TELEPHONE NUMBER (Include Area Code) d. E-MAIL ADDRESS
e. REGISTRATION OFFICIAL'S SIGNATURE f. DATE SIGNED (YYYYMMMDD)
DD FORM 2842, AUG 2009 PREVIOUS EDITION IS OBSOLETE. A copy of this form shall be provided
to the Subscriber.
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