CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
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S S:S
SS

PHIU YU CU CUNG CP CHNG TH S VIETTEL-CA

I. Thng tin v t chc, doanh nghip
1. Tn giao dch bng ting Vit
Tn giao dch y :...........................................
Tn vit tt:..............................................................
Trc thuc :......................
2. Tn giao dch bng ting Anh.......
3. Thng tin ca t chc, doanh nghip
Quyt nh thnh lp s/Giy php KKD: .......
Cp ngy: .T chc cp:...
M s Thu: .........
4. a ch ca t chc, doanh nghip (theo quyt nh thnh lp/Giy php KKD)
a ch :...
Qun/Huyn.Thnh ph/Tnh:........................
5. Email giao dch chnh thc:..
II. Khch hng c nhn/ i din php l ca t chc, doanh nghip
H v tn :..Chc v:
S CMND/H chiu: Cp ngy: .. Ti:
H khu thng tr:...
in thoi:..Di ng: .
Email:...:.................................Fax:.......................................................
III. Thng tin lin h trong trng hp cn thit
H v tn:Chc v: .
a ch:
in thoi:...Di ng: .
Email:..:.......................................Fax:..................................................
IV. Thng tin v chng th s Viettel-CA xin cp:
1. i tng xin cp dch v:

C nhn

T chc

2. Loi chng th xin cp:

Chng th s cho c quan, t chc, c nhn
Chng th s SSL
Chng th s Code Signing
3. Thi hn s dng: T :., ././

n: .,././.

4. Tn min ng k (bt buc vi chng th s SSL):.

5. Giy php tn min s (bt buc vi chng th s SSL):.....
, ngy ...... thng ... nm.
i din ca t chc, doanh nghip
(K, ghi h tn v ng du)

Ngi tip nhn yu cu

(K v ghi r h tn)

BM01.QT.03.KHDN.24

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