Subscribers' GTI Certificates are to be issued on behalf of the Customer; ... we
agree to comply with the terms and conditions set out in GTI Service Supplement,
...
IMPORTANT: To expedite the processing of your application, please complete in full and return completed form to Standard Chartered Bank, Solution Delivery
GTI Certificate Request Form To: Standard Chartered Bank Please Tick Ö Your Choice New Amend Customer Profile Company Name (herein known as Customer) + Domicile Country+
Subscribers (Detailed information in attached Subscriber Schedule) Subscriber Name 1
Subscriber Name 6
Subscriber Name 2
Subscriber Name 7
Subscriber Name 3
Subscriber Name 8
Subscriber Name 4
Subscriber Name 9
Subscriber Name 5
Subscriber Name 10
Customer’s Authorised Signatory Declaration We/I hereby confirm that: - we are/I am authorised signatory for the Customer; - the personal and employment details provided on this form are complete and accurate, and you will be notified by the Customer of any changes in such details from time to time; - the Subscribers are employed by the Customer; - Subscribers’ GTI Certificates are to be issued on behalf of the Customer; - a copy of the Master Services Agreement Application Form signed by an authorised signatory of the Customer is attached to this Form; - we agree to comply with the terms and conditions set out in GTI Service Supplement, all of which we have read and understood; and - we acknowledge that the Subscriber Schedules attached to this form, form part of it.
CUSTOMER
X
X
Authorised Signatory and Company Stamp
Authorised Signatory and Company Stamp
Name
Name
Title
Title
Date
Date
Note: + Mandatory Form Name: GTI Certificate Request Form Version 1.1
GTI Certificate Request Form – Subscriber Schedule This GTI Certificate Request Form has attached to it a copy of the Data Protection and Privacy Statement. By signing this GTI Certificate Request Form you consent to the use of your personal data contained in this Form in the manner contemplated by the Data Protection and Privacy Statement as amended from time to time (the “Statement”). Your personal data may be transferred to SCB Group companies and third parties including third party processing agents and alliance banks appointed by us and located in countries that do not offer the same level of statutory data protection as in your own jurisdiction. SCB appreciates the value of your personal data and shall take all reasonable contractual and procedural steps necessary to protect and maintain the security of your personal data. Your attention is drawn to our Data Protection and Privacy Policy (the “Policy”) that can be found at http://www.standardchartered.com/global/home/datapp.html. By signing this GTI Certificate Request Form, you agree that you are consenting to the use of such personal data in the manner and for the purposes contemplated above and in the Statement and the Policy. Subscribers List (As authorised by Customer Signatories) Subscriber Name+
Distinguished Name#+ 1st choice
Department Name+
2nd choice
Email Address+
3rd choice
Smart Card Reader Requirements: Smart Card Reader Required ( Y / N ) If yes, what kind of smart card reader do you need? Connected via COM port Connected via USB port +
Connected via PCMCIA port
Subscriber Name
Distinguished Name#+ 1st choice
Department Name+
2nd choice
Email Address+
3rd choice
Smart Card Reader Requirements: Smart Card Reader Required ( Y / N ) If yes, what kind of smart card reader do you need? Connected via COM port Connected via USB port +
Distinguished Name#+ 1st choice
Department Name+
2nd choice
Email Address+
3rd choice
Smart Card Reader Requirements: Smart Card Reader Required ( Y / N )
+
Signature+
Connected via PCMCIA port
Subscriber Name
Distinguished Name#+ 1st choice
Department Name+
2nd choice
Email Address+
3rd choice
Smart Card Reader Requirements: Smart Card Reader Required ( Y / N ) If yes, what kind of smart card reader do you need? Connected via COM port Connected via USB port
Signature+
Connected via PCMCIA port
Subscriber Name
If yes, what kind of smart card reader do you need? Connected via COM port Connected via USB port
Signature+
Signature+
Connected via PCMCIA port
Note: + Mandatory # Distinguished Name will be printed on your GTI Smart Card; Maximum of 30 Characters including space Allowable characters for Distinguished Name and Department: Alphabets, Numbers, Space, Full Stops, Commas and Single Quotes. Form Name: GTI Certificate Request Form Version: 1.1
