Application for the issue of electronic certificate

Application for the issue of electronic
certificate
page: 1 of 3
A
BIC:
H
I,J
Date:
Ref:
rel. Ref:
L
Responsible CB: ES - Spain
1. General Data for Requestor
10
Company Name of Requestor:
11
Company Address of Requestor:
Enter Company
Name and
Address of
Requestor
2. CERTIFYING ENTITY
21
Certifying Entity:
Banca d'Italia
Select Certifying
Entity
3. REQUEST CONTENT
31
I the undersigned
hereby request the authentication certificate. (indicate the given name
and family name of the holder)
Form No C100
For this purpose I provide the required information below and
undertake to promptly communicate every change therein.
Banco de España - Sistemas de Pago
Calle Alcalá, 48 28014 Madrid
Teléfono + 34 91 338 5402 / 5788 Fax + 34 91 338 6088 [email protected]
Enter Name of
Requestor
Application for the issue of electronic
certificates
Page 2 of 3
Form No C100
4. Personal data
Enter Personal
Data
41
Family name(s):
41b
Given name(s):
42,42b
Sex:
43
Country of birth:
43b
Province of birth:
43c
Municipality of birth:
44
Tax identification number (or equivalent):
45
Identification document (indicate the essential data of the
identification document):
- Select -
Date of birth:
Banco de España - Sistemas de Pago
Calle Alcalá, 48 28014 Madrid
Teléfono + 34 91 338 5402 / 5788 Fax + 34 91 338 6088 [email protected]
Application for the issue of electronic
certificates
Page 3 of 3
5. DECLARATION PART
I attach a photocopy of the identification document
mentioned under 45.
51
Enter Data
I declare, moreover, that I:
am informed of the conditions for using the certificates in
question, specified in the User Manual and
supplementary provisions issued by the Certification
Entity, and undertake not to use them for functions or
purposes other than those established by the
Certification Entity;
52
53
have received the attached information note on the
protection of personal data.
Date,
Name(s)
Requestor Signature
The undersigned declare(s) to have full capacity and authority to sign this form for
and on behalf of the Credit Institution above and that the designated requestor has an
employment or agency relation with the latter.
Form No C100
Date,
Name(s)
Legal Representative Signature(s)
Banco de España - Sistemas de Pago
Calle Alcalá, 48 28014 Madrid
Teléfono + 34 91 338 5402 / 5788 Fax + 34 91 338 6088 [email protected]
Information
note
on
protection
of
personal data
In conformity with the requirements of Legislative Decree 196/2003 of the Italian Republic,
you are informed that Banca d’Italia processes the personal data that you provide upon
applying for the issue of electronic certificates.
The data are necessary for the issue and management of electronic certificates by Banca
d’Italia.
The data are processed with IT procedures and logics strictly correlated to the abovementioned purposes and with the use of security measures that ensure the confidentiality
of personal data and prevent access to such data by unauthorized third parties or
personnel.
The data are not communicated to third parties, nor are they disseminated.
The data may become known to:
1) in their capacity as persons responsible for processing, the Manager of the SSP
Service Desk / other individuals at each NCB to which the application was submitted;
the Head of the Organization Department, which operates the certification service and
authorizes the requests relative to the life cycle of certificates; and the Head of the
Information Technology Department, which produces the certificates;
2) in their capacity as assigned persons, the personnel of the units assigned, case by
case or permanently, to perform the above-mentioned activities.
You may refer to Banca d’Italia (Organization Department), via Nazionale 91, 00184
ROME, Head of Processing, or to the persons responsible for processing indicated
above, to exercise your right to access your personal data and the other rights recognized
by Article 7 of Legislative Decree 196/2003, including: the right to know the origin of the
data and the purposes for and manner in which it is processed; to have the data updated,
corrected or supplemented; to obtain the deletion, transformation into anonymous form or
blocking of the data that are processed in violation of the law; to object in whole or in part,
Form No C110
for legitimate reasons, to processing.
Banco de España - Sistemas de Pago
Calle Alcalá, 48 28014 Madrid
Teléfono + 34 91 338 5402 / 5788 Fax + 34 91 338 6088 [email protected]