국외소재업체 인증서 신청서

별지 제4호 서식(제13조의2 제2항)]

국외소재업체 인증서 신청서 (Application for Certification Service)

수신 : 대한민국 조달청장(To: Administrator, PPS)		던스번호 (DUNS Number)
*회 사 명 (Name of Firm)		사업자등록번호 (Taxpayer ID No.)
*대표자명 (Name of Chief Executive)		*E-mail
*회사주소 (Address of Firm)		*전화번호(Tel. No.)
		*Fax 번호(Fax No.)
인증기관	한국정보인증 주식회사
*한국 내에서 연락가능한 대리인에 대한 기재사항을 기입해 주십시오 (Please fill out the mentioned items about your agent who is contactable in Korea)   ○ 대리인 이름 ○ 사무실 전화번호 (Name of agent) (Office phone No.)   ○ 휴대전화 번호 ○ 팩스번호 (Mobile phone No.) (Fax No.)   ○ 주소 (Address)   ○ 이메일 (E-mail)

I, as a legal representative of the firm whose name appears above, hereby apply for electronic certification service. I also hereby affirm that, in application for certification service and use of the certificate, I will abide by the responsibilities and liabilities of subscribers and rules relating to the use of certificate in accordance with Certification Practice Statement and Terms of Use for Certification Service established by the certification agency (KICA Inc.).

*날짜 (Date)

*대표자명 (Name of Chief Executive)

*서명 또는 증명인감 (Signature or Seal)

Agreement on Collection and Use of Personal Information and Provision to Third Party * I agree to the following terms of collection and use of personal information □ : I, the applicant(s) whose name(s) appears above, hereby agree that the Administrator of Public Procurement Service retain and use my personal information contained in this application until my certificate expires (including termination), for the purpose of certificate issuance and management. I will not object to or challenge the denial of certificate issuance on the basis of my non-agreement to this terms of collection and use of personal information.   * I agree to the following terms of provision personal information to third party □ : I, the applicant(s) whose name(s) appears above, hereby agree that the Administrator of Public Procurement Service provide my personal information contained in this application, until my certificate expires (including termination), to KICA Inc., for the purpose of certificate issuance and management. I will not object to or challenge the denial of certificate issuance on the basis of my non-agreement to this terms of collection and use of personal information.   ※ Please check the boxes to confirm your Agreement on Collection and Use of Personal Information and Provision to Third Party

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